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Full text of "The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 1)"

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THE 



CYCLOPEDIA 



OF 



PRACTICAL MEDICINE. 



VOL. I. 



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THE 



CYCLOPAEDIA 



OF 



PRACTICAL MEDICINE: 



COMPRISING 

TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA 
AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC., ETC. 

EDITED BY 

JOHN FORBES, M.D. E.R.S. 

PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC. 

ALEXANDER TWEEDIE, M.D. F.R.S. 

PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING- HOSPITAL, ETC. 

JOHN CONOLLY, M.D. 

LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO 
THE H4NWELL LUNATIC ASYLUM, ETC. 

THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY 

ROBLEY DUNGLISON, M.D. 

PROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, 
LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. 



** Hec deraum sunt quae non subgessit phantasiie imaginatricis temeritas sed phenomena practica 
edocuere." — Sydenham. 



IN FOUR VOLUMES. 
VOL. I. 

ABDOMEN — EMMENAGOGUES. 




ARAL'S OFFJC 

/ 63 n 



PHILADELPHIA: 
BLANCHARD AND LEA. 

1859. 






v.\ 



Entered, according to Act of Congress, in the year 1845, by 
LEA AND BLANCHARD, 

in the clerk's office of the District Court of the United States for the Eastern District 

of Pennsylvania. 



FAGAN, -STEREOTYPER. 



COLLINS, PRINTER 



,^ 



PREFACE OF THE AMERICAN EDITOR. 



It is now upwards of twenty years since the undersigned agieed to 
engage with Dr. Copland and the late Dr. Gordon Smith, in the preparation 
of an Encyclopaediac Dictionary of Practical Medicine, which should hold 
the same relation to the department of Medicine, that Mr. S. Cooper's Sur- 
gical Dictionary does to that of Surgery. The project was conceived and 
advertised in the year 1824, in the " London Medical Repository," of which 
Dr. Copland and the undersigned were editors. A prospectus of the under- 
taking was drawn up, and arrangements were made for its publication with 
the Messrs. Underwood, of London. Towards the latter end of that year, 
the undersigned left England for the University of Virginia ; and the panic, 
which prevailed in 1825 in the commercial world, according to Mr. Petti- 
grew, (Medical Portrait Gallery, Art. Dr. Copland,) caused the publishers 
to relinquish the undertaking. It probably, however, gave the impulse to 
the appearance of the " Cyclopedia of Practical Medicine," of Drs. 
Forbes, Tweedie, and Conolly. Of the signal value of this great work, 
there is but one sentiment. The general voice of the profession everywhere 
nas, indeed, sufficiently shown, that the hope expressed by the British 
editors, in their Preface, has been amply realized. It is admitted, that they 
have prepared a work required by the present wants of medical readers, 
acceptable to the profession in general, and in all respects " a standard 
work on the Practice of Medicine." It was for this reason, and owing 
to the high opinion expressed of its merits by those on this side of the 
Atlantic, who had the good fortune to consult its pages, and to the anxiety 
of the best informed that it should be rendered more available to the pro- 
fession in this country, that the publishers determined, at a great outlay of 
money and of labour, to reprint it. 

At their request, the undersigned consented to superintend the repub- 
lication, to revise the various articles, and to make such additions and 
modifications as he might deem desirable. To this determination he was 
impelled, in part, by his knowledge of the accomplished editors, and his 
consequent anxiety, that the different articles should be preserved, as far as 
practicable, in their pristine integrity. Generally speaking, they were so 
full and comprehensive, that but little modification seemed to be necessarj 
In all cases, however, the undersigned has endeavoured to add the facts and 



vi PREFACE OF THE AMERICAN EDITOR. 

opinions, which form part of the medicine of the day, and to omit nothing 
calculated, in his view, to throw additional light on the subjects canvassed. 
These additions he has striven to make in such a manner as not to interfere 
with the general tenor of the articles ; and to cause them to read as if they 
had proceeded from the pen of the original writers. The interstitial additions 
are enclosed in brackets [ ]. Besides these, he has inserted different topics, 
which had been wholly omitted in the English edition, some of which are 
essentially American in their character. To these additions his signature 
is appended. For one article, on the History of American Medicine before 
the Revolution, he is indebted to Dr. J. B. Beck, of New York. 

In making these additions, the undersigned has endeavoured to be as 
brief as perspicuity would permit ; and, where his opinions have been fully 
expressed elsewhere, — to avoid repetition, he has referred to them for further 
details. On every occasion he has been anxious to cite the views and 
observations of cotemporary, and particularly of American, writers, where 
such views and observations appeared to him to merit especial notice. 

Appearing, as the work originally did, in parts, articles were necessarily 
omitted in their proper places, and many were thrown into a supplement. 
This defective arrangement has been rectified as far as was practicable, so 
that the American edition will, in this respect, be found to possess advan- 
tages, as a book of reference, over its English prototype. 

The History of Medicine, which, in the English edition, was prefixed to 
the alphabetic portion, takes its proper place in the third volume of the 
American edition. 

One subject only has been omitted — Medical Bibliography — which formed 
an appendix to the last volume of the English edition, and was subsequently 
published in a distinct form. This the publishers determined to discard, in 
consequence of the additional cost to the purchaser, which its insertion 
would occasion ; and of their conviction, that notwithstanding its intrinsic 
value to a few, and the high character of its author — Dr. Forbes — it would 
be considered wanting in interest and importance to the many on this side 
of the Atlantic, who will seek the work as a guide to Practical Medicine. 

ROBLEY DUNGLISON. 



PREFACE FBOM THE ENGLISH EDITION. 



The Editors have at length the gratification of laying the Cyclopaedia of Prac- 
tical Medicine before the public ,in a completed state. 

It is impossible for them to look at the list of the Contributors by whose assist- 
ance this work has been accomplished without a deep-felt satisfaction ; distinguished 
as that list is by so many names of celebrity in modern medicine, and including so 
many of the professors and teachers in London, Edinburg, Dublin, and Glasgow, 
whose reputation conveys a high and just authority to their doctrines. To have 
directed some part of the scientific exertions of such writers to the pages of the 
Cyclopaedia, and, also, to have elicited from not a few of the most accomplished 
among the provincial physicians of the empire, numerous and valuable contributions 
which but for the comprehensive plan of this work might never have been commu- 
nicated to the profession, is a result to which the Editors must e ?er feel proud and 
gratified to have conduced. 

With such efficient aid in all the parts of their undertaking, they have spared 
no personal pains, in the hope by uniformity of plan, simplicity of arrangement, 
and the harmony and consistency of its several portions, to make the Cyclopaedia 
fully and fairly to represent the state of Practical Medicine at the time of its 
appearance. From innumerable foreign and domestic sources the scattered know- 
ledge which has so fast accumulated since the commencement of the present 
century has thus been gathered together, and placed at the command of every 
reader of the English language. Those acquainted with the actual limitation of 
such knowledge before the appearance of this work, and who have opportunities of 
knowing how slowly even valuable novelties are diffused in a form giving any 
assurance of their worth, will best be able to appreciate the importance of the 
extensive means of reference which the Cyclopaedia has at once introduced into 
the library of many English practitioners at home and abroad. 

The ambition of the Editors was not limited to the formation of a mere manual, 
fitted for those who only demand the smallest supply of exact intelligence with 
which practice can be carried on, or professional station maintained without a 
palpable exposure of ignorance. Their object was no less than to prepare a com- 
pendium of the best parts of ancient and modern medicine, theoretical and practical ; 
not passing over with disregard the vast literature of the ancient writers, but rather 
rescuing it from the voluminous oblivion in which much of it was lost ; and also 
collecting with care the more accurate, condensed, and applicable knowledge of 
modern authors and of modern times into a liberal and consistent system, from 
works little known to the generality of English readers, and familiarly known to 
very few. 

Thus, whilst the great claims of the older cultivators of medicine have never 
been forgotten, the labours of the moderns, and more particularly of the French, 
German, and Italian pathologists, by which, conjointly with those of British prac- 
titioners, the whole face of practical medicine may be said to have been changed, 
have attracted the most diligent and thoughtful attention. The learned reader 

(vii) 



viii PREFACE FROM THE ENGLISH EDITION. 

does not require to be assured that the task of reference for specific information to 
many older works, once of high and deserved authority, and still esteemed, is often 
both tedious and little profitable, whilst their ample volumes yet contain much 
valuable matter, not unworthy of preservation, and which it is no fruitless employ- 
ment to endeavour to place along with the better arranged facts of later writers, in 
one view, before the practitioner and the student. Throughout the prosecution of 
this large design, it has never been forgotten that the Cyclopaedia would be referred 
to by various readers for various objects ; by the young practitioner as the guide 
and counsellor of practice, especially when beset with practical difficulties ; by the 
older practitioner for complete and concise information, and for medical learning 
not scanty and illiberal, but without scholastic pedantry ; and by the student for 
applicable knowledge, suited to the actual time, collateral with and auxiliary to his 
prescribed studies, and satisfactorily directing the efforts of his inquiring mind. 

At the commencement of such an undertaking, it was difficult not to call in 
question the probability of its meeting with adequate encouragement. No such 
work existed in this country ; and although works on a plan somewhat similar had 
been very favourably accepted on the Continent, still it might have been urged that 
the English were eminently, almost exclusively, a practical people, — that their 
medicine, in the opinion of foreign critics, who appeared to be dispassionate and 
impartial, was essentially empirical, — and that until a very recent period undeniable 
prejudices existed in the minds of many English practitioners of known practical 
skill, against all attempts to append theory to the deductions of mere experience. 
Of the English works known to have been most profitable to their publishers, many 
were mere compilations, or of a description adapted to the contracted prejudices 
just alluded to; whilst works which have been thought deserving of translation 
into more than one foreign language, and had reflected honour on British pathology, 
had in our own country met with comparative neglect. 

The progress of medicine during the last forty years had led to successive 
editions of the few systematic works already existing, to which the recent acquisi- 
tions of medical science were somewhat inconveniently, because incongruously, 
attached. The cultivation of general anatomy, the changes effected in physiology, 
and the immense advancement of the knowledge of morbid structure, required that 
the whole of Practical Medicine should be presented in that reconsidered and 
augmented state which had been the result of this progression. Several parts of 
medical study, bearing closely upon practice, had moreover undergone so much 
recent investigation as almost to constitute them new parts of medical science ; — 
such as the effects of Climate on health and disease ; the properties of Mineral 
Waters ; the mode of action of Poisons, and indeed the whole subject of Medical 
Jurisprudence ; as well as the new methods of exploring diseases of the chest and 
abdomen ; the laws of epidemics, and the means of promoting disinfection ; with 
many other questions of considerable interest. The greater intercourse which had 
taken place during a period of nearly twenty years of peace, between this country 
and the Continent, had opened, vast stores of pathological facts, in connection with 
almost every known disease, which yet remained imperfectly known to many to 
whom a general work would be accessible, and which no editor had yet sought to 
arrange and collate with the contemporaneous discoveries of our own authors or to 
combine with the practical improvements acknowledged in our own country. 
Between respect for the old writers, and the continual contradictions of them 
occurring in those of later date ; between the fame of the Continental authorities 



PREFACE FROM THE ENGLISH EDITION. IX 

and a lingering attachment to opinions of which all the foundations had been 
shaken ; .he student of medicine and the young practitioner found themselves 
embarrassed in the attempt to arrive at stable conclusions, or even to comprehend 
the actual state at which medicine had arrived, and which no general work at that 
time represented. 

All these circumstances encouraged the presumption that if a work embodying 
all these improved parts of medical knowledge, — simply and conveniently arranged, 
and not unenriched by the treasures of an older period — full and accurate, but from 
which all the superfluous matter that had been admitted into some foreign works of 
a like form was carefully excluded, — were offered in the English language, its 
reception would be such as to satisfy all who were concerned in it, whilst its pre- 
paration would reflect no discredit on those who undertook it. 

It was in no small degree gratifying to the Editors to find that the publication 
of the early numbers of the Cyclopaedia was attended with circumstances which 
conveyed an assurance of the general correctness of these views. The circulation 
of the work soon extended to every portion of the British empire, to the Colonies, 
and to America ; and the publishers have from time to time informed them that its 
sale was steadily proceeding. The Editors have undoubtedly received these inti- 
mations with pleasure ; not only because they were connected with benefit derived 
by those who had adventured in a liberal undertaking, but because they thought 
they perceived in such circumstances a proof of an increasing zeal for exact and 
comprehensive knowledge on the part of British practitioners of every rank, in 
every part of the world. 

However natural and proper it may be for the Editors to take a retrospective 
survey of the work when it is brought to a conclusion, and to examine with what 
fidelity they have fulfilled their engagements, and how far and how equally the 
various departments of practical medicine have in their turn occupied their atten- 
tion, it is hardly possible to express the results of this retrospection in words which 
will not expose them to the charge of being disposed to look back upon their exer- 
tions with too much complacency. Yet they may perhaps be allowed to say, that 
if the reader will take the trouble to inspect the mere titles of the articles con- 
tained in these columns, comprehending nearly three hundred original essays of 
known and distinguished authors, and will bear in mind either the leading physio- 
logical divisions of diseases, or consider them with reference to the head, the chest, 
the abdomen, the surface, or the general condition of the body ; as well as the 
subjects of obstetrical medicine, materia medica, or medical jurisprudence ; he 
will sufficiently appreciate the care bestowed to make the Cyclopaedia satisfactory 
to all who refer to its pages, and at the same time strictly a book of practicaJ 
reference. No subject, it is believed, immediately practical in its nature or appli- 
cation, has been left out, although unnecessary disquisition has been as much as 
possible avoided. 

It has consistently entered into their plan to admit of a far wider range ol 
eiibjects than appears heretofore to have been considered necessary in works pro- 
fessedly written on the practice of medicine, but a range comprising many new 
subjects of extreme importance to those engaged in practice or preparing for it.. 
Such are the subjects of Abstinence, Acupuncture, Age, Change of Air, Antiphlo- 
gistic Regimen, Asphyxia, Auscultation, Bathing, Bloodletting, Morbid States ol 
the Blood, Climate, Cold, Contagion, Convalescence, Counter-irritation, Derivation, 
Congestion and Determination of Blood, Dietetics, Disinfection, Physical Educa- 



x PREFACE FROM THE ENGLISH EDITION. 

tion, Electricity, Endemic Diseases, Epidemics, Expectoration, Exploration of the 
Chest and Abdomen, Galvanism, Hereditary Transmission of Disease, Induration, 
Irritation, Infection, Latent Diseases, Malaria and Miasma, Perforation, Prognosis, 
Pseudo-morbid Appearances, Pulse, Softening, Medical Statistics, Stethoscope, 
Sudden Death, Symptomatology, Temperament, Toxicology, Transformations, Trans- 
fusion, Tubercle, Ventilation, Mineral Waters ; and those of various general arti- 
cles on the pathology of organs. 

The several articles relating to Diseases of the Brain and Spinal Chord, and of 
their membranous coverings, including the important subject of the impairment of 
the mental manifestations, will probably be deemed by every candid reader to 
contain accurate views of morbid structure and faithful descriptions of the most 
important lesions of the nervous functions. How great the talent and how high 
the authorities on these subjects, will be at once seen by referring to the names of 
the authors of the articles Apoplexy, Inflammation of the Brain, Catalepsy, Chorea, 
Coma, Convulsions, Delirium, Epilepsy, Headach, Hydrocephalus, Hydrophobia, 
Hypochondriasis, Insanity, Latent Diseases, Paralysis, Plethora, Prognosis, Som- 
nambulism, Diseases of the Spinal Marrow, Temperament, Tetanus, Wakefulness, 
&c. As regards the greater number of the authors of these articles, they are well 
known to have been previously in much esteem with the public for treatises more 
or less connected with the subjects on which they undertook to write for the 
present work. 

The direction for many previous years of the attention of one of the Editors to 
Diseases of the Chest could not but make both him and his colleagues particularly 
desirous that on the subjects of the numerous and serious diseases of the lungs and 
of the heart, the Cyclopaedia should contain the fullest and the most recent informa- 
tion ; and that the novel and still too much neglected methods of physical investi- 
gation of Auenbrugger, Laennec, Andral, Piorry, and others, should be clearly and 
perfectly set forth. In the articles relating to these various maladies, contributed 
by Dr. Carswell, Dr. Cheyne, Sir James Clark, Dr. Darwall, Dr. Hope, Dr. Johnson, 
Dr. Law, Dr. Townsend, Dr. Williams, &c. it is hoped that no omissions will be found. 
These names are for the most part so familiar to the profession, in connection with 
the several subjects on which they have written in the Cyclopaedia, that the titles 
of the different articles would alone have suggested them, in order to give the 
stamp of valuable authority to each. 

As regards Diseases of the Abdomen, it may without any impropriety be men- 
tioned that, in the articles Cholera, Colic, Diarrhoea, Dysentery, Enteritis, 
Epidemic Gastric Fever, Gastritis, Gastrodynia, Gastro-enteritis, Haematemesis, 
Hemorrhoids, Indigestion, Jaundice, Inflammation of the Liver, Peritonitis, Pyrosis, 
Tabes Mesenterica, Tympanites, Worms, Organic Diseases of the Stomach, Liver, 
Pancreas, Kidneys, &c. &c, is included a more elaborate and practical exposition 
of the pathology and symptomatology of the affections of the abdominal viscera 
generally, and of the gastro-intestinal mucous membrane in particular, than is 
contained in any single work previously published. The importance of correct 
views of this large class of common and much diversified disorders, as a basis of 
useful practice, is such as it would be quite needless to dilate upon. They involve 
consequences most seriously affecting the health of the body and the mind ; and 
the mismanagement even of the lighter forms is largely productive of human dis- 
comfort and unhappiness. They are also, in some form or other, incidental to every 
constitution, and are literally of daily and hourly occurrence. From fever, the 
severest of the acute diseases from which medical care effects frequent recovery, 



PREFACE FROM THE ENGLISH EDITION. XI 

to the habitual distresses produced by the imperfect digestion of food, they demand 
the continual attention of the practitioner. The relations of gastro-intestinal 
irritation with numerous disorders of the chest, head, skin, and extremities, and 
with fever, as causes or effects, are among the most interesting questions which 
have been agitated by the most eminent of modern physicians in this and in other 
countries, and the practical application of the researches of pathologists concerning 
the morbid states of the digestive mucous membrane remains an object anxiously 
sought by those acquainted with the exigences of various practice, and who are 
not content to practise without reflection. 

So indiscriminate, also, generally speaking, is the treatment of the various modi- 
fications of indigestion, — the chronic irritations of the intestines are often so long 
overlooked, — so empirically are undefined disorders of the liver prescribed for, — 
and the conduct of the dietetical part of practice, even in fevers, and still more in 
chronic disorders, is so capricious, — that it may be permitted to the Editors to hope 
that some improvement may ensue from the circulation of the sounder and better 
founded notions of pathology and practice explained and advocated in the various 
essays on abdominal diseases which contribute to give value to these volumes. 

The department of Cutaneous Diseases has, it will be seen, engaged the pens of 
Dr. Corrigan, Dr. Cumin, Dr. G. Gregory, Dr. Houghton, Dr. Joy, Dr. Kerr, Dr. A. 
T. Thomson, and Dr. T. J. Todd, by whom, as was to be expected, this important 
branch of study, which enjoys but a small share of popularity in this country, has 
received full pathological and practical illustration. 

As regards some affections implicating the whole system, and particularly the 
fluids, it is but just to allude to the admirable treatises on Gout and Plethora, as 
being worthy of the high reputation before attained by the author of them as a 
philosophical physician and an experienced practitioner. Nor can the Editors pass 
silently over the elaborate article on Tubercular Phthisis, of which it is but one 
among many excellences that it invites the attention from that contemplation of 
local lesions which leads to practical results of little value, to a more enlarged con- 
sideration of the subject, pregnant with the most momentous practical consequences. 

The names of Dr. Marshall Hall, Dr. Lee, Dr. Locock, and Dr. Montgomery, 
affixed to the several articles connected with the Diseases of Women and Children, 
will be a sufficient assurance to every reader that this responsible part of medicine 
has not been confided to inefficient hands. Nothing could be more compatible 
with the plan of the Cyclopaedia than the brief, clear, and instructive essays 
furnished by these able and experienced practitioners. 

In the interesting field of Medical Jurisprudence the work has been benefited 
by the original and masterly dissertations of Dr. Arrowsmith, Dr. Beatty, Dr. 
Christison, Dr. Montgomery, and Dr. Prichard. 

The well-earned fame of Dr. A. T. Thomson gives to his numerous contributions 
on subjects comprehended in the department of the Materia Medica, an interest 
of which every student must be fully sensible ; and it is but just to mention that 
for the limitation of these articles within narrower bounds than those which the 
author deemed essential to their full value, the Editors are solely accountable. 
With respect to the practical application of some other medical agents, as Galva- 
nism and Electricity, the reader is enabled to avail himself of the valuable informa- 
tion communicated by Dr. Apjohn, and marked by his characteristic accuracy. To 
the same able writer the Editors have been indebted for the comprehensive treatise 
on Toxicology. In the parts of the work closely allied to chemical science, as ir 
the articles Calculi and Mineral Waters, the Editors have been honoured by the 



xii PREFACE FROM THE ENGLISH EDITION. 

contributions of Dr. Thomas Thomson, of Glasgow, who has been long known to 
the whole scientific world as one of the greatest authorities in modern chemistry. 

The value of the aid afforded in the general articles relating to various parts of 
Morbid Anatomy, will be understood by all who know the great and deserved 
reputation of Dr. Carswell, both in England and on the Continent ; a reputation 
which cannot but derive increase by his great work on that subject, and its incom. 
parable pictorial illustrations, now in the course of publication. 

Many able contributions, not specially alluded to in these observations, demand 
the general and warm acknowledgements of the Editors, as of a character not 
inferior to any which have been mentioned; and their especial obligations to Dr. 
Alison and Dr. Bostock will be evident to all who peruse with attention the Histo- 
rical sketches prefixed to the practical portion of the Cyclopaedia. 

As tending in a considerable degree to place the contents of the work more 
completely before the reader for immediate consultation, and therefore important, 
although laying no claim to merit in itself, the Editors have added a very minute 
and extensive General Index. 

Hoping to be excused for making these reflections on a work now laid before the 
profession in a finished state, the Editors will only add, that they have avoided 
multiplied and artificial divisions, and have aimed at that plainness of arrangement 
which most facilitates a ready and immediate reference. They have also shunned 
the fault of encumbering medical literature with new and uncouth terms, always 
preferring those in common use, and of which the signification was the least 
doubtful. It has been their constant desire to guard the most inexperienced reader 
from distraction in the pursuit of practical knowledge, and to assist the more 
advanced reader in the grouping and generalization of the ideas with which his 
personal experience may have imbued him. 

One of the most delicate parts of the duty of the Editors in conducting these 
pages from their commencement to their termination, has been the occasional 
adaptation of the articles composing it to the character or to the proposed size of 
the whole work. Considerations which could not properly be put aside sometimes 
caused modifications to be absolutely necessary, in contributions which might have 
been published unchanged as separate essays. To say that this duty was in every 
case performed without difficulty, or with the entire and ready acquiescence of the 
writers, would be to assert what none who are versed in literary composition, or who 
know the natural feelings of authors, would give credit to. That it was always 
performed with a sincere regard to such feelings, and that no change of arrange- 
ment, and even no verbal alteration, was made without just deliberation, they may 
very truly affirm. They have the satisfaction of believing that such is the impres- 
sion left on the minds of those contributors who have honoured them with their 
assistance. With many, before unknown to them, except by reputation, the Editors 
have the happiness to feel assured that permanent freindship has arisen out of 
what was at first but casual co-operation. 

In conclusion, the Editors entertain a hope that they have prepared a work 
required by the present wants of medical readers, acceptable to the profession in 
general, and so capable by its arrangements of admitting the progressive improve- 
ments of time, as long to continue what the general testimony of their medicai 
brethren, as far as it has hitherto been expressed, has already pronounced it. to be, 

standard British work on the Practice of Medicine. 

If sucli should prove to be the event, they will feel themselves abundantly repaid 
for the labours which it has imposed upon them. 



LIST 



CONTRIBUTORS 



CYCLOPEDIA OF PRACTICAL MEDICINE, 



THE ARTICLES WRITTEN BY EACH AUTHOR. 



Alison, W. P., M.D. F.R.S.E. Professor of 
Medicine in the University of Edinburgh, &c. 

Medicine, history of, in the present century. 

Apjohn, James, M. D. M.R.I.A. Professor of 

Chemistry to the Royal College of Surgeons 

in Ireland. 

Combustion, spontaneous human. 

Electricity. 

Galvanism. 

Toxicology. 

Arrowsmith, R., M.D. Physician to the Co- 
ventry Dispensary. 

Infanticide. 

Ash, Edward, M.D. Physician to the Norwich 
Dispensary. 

Hiccup. 

Prognosis. 
Syncope. 

Bardsley, James L., M. D. Physician to the 
Manchester Royal Infirmary, Dispensary, 
&c. 

Diabetes. 
Hydrophobia. 

Barlow, Edward, M.D. Physician to the 
Bath United Hospital and Infirmary. 

Antiphlogistic regimen. 

Congestion of blood. 

Determination of blood. 

Education, physical. 

Gastrodynia. 

Gout. 

Plethora. 

Rheumatism. 

Be.vtty, Thomas Edward, M.D. Professor of 
Medical Jurisprudence to the Royal College 
of Surgeons in Ireland, and Consulting 
Accoucheur to the Baggot-Street Hospital, 
Dublin. 

Impotence. 

Dead, persons found. 

Rape. 

Sex, doubtful. 

(Survivorship. 

Wounds, death from. 



Beck, J. B., M.D. Professor of Materia Medica, 
in the College of Physicians and Surgeons, 
New York. 

Medicine, American, before the Revolution, 
History of. 

Bigsby, John J., M.D. F.L.S. Senior Physi- 
cian to the Newark Dispensary. 

Spleen, diseases of. 

Bostock, J., M.D. V.P.R.S. F.L.S. F.G.S. 
&c. &c. 

Medicine, history of. 

Pulse. 

Urine, morbid states of the. 

Brown, Joseph, M.D. Physician to the Sun- 
derland and Bishopwearmouth Infirmary. 

Cholera. 

Contagion. 

Disinfection. 

Dysentery. 

Fever, intermittent. 

remittent. 

hectic. 
Hereditary transmission of disease. 
Infection. 

Malaria and miasma. 
Plague. 
Ventilation. 

Bijrder, Thomas H., M.D. Member of the 
Royal College of Physicians, London. 

Erethismus mercurialis. 

Headach. 

Jaundice. 

Burne, John, M.D. Physician to the Carey- 
Street Dispensary. 

Otalgia and Otitis. 
Hemorrhoids. 

Carswell, Robert, M.D. Late Professor of 
Morbid Anatomy in the University of Lon- 
don. 

Induration. 

Melanosis. 

Mortification. 

Perforation 01 the hollow viscera 

Scirrhus. 

Softening of organs. 

Tubercle. 

(xiii 



LIST OF CONTRIBUTORS. 



XIV 

Carter, H. W., M.D. F.R.S.E. Physician to 
the Kent and Canterbury Hospital. 
Delirium tremens. 
Ischuria renalis. 
Kidneys, diseases of. 
Nephralgia and Nephritis. 
Pancreas, diseases of the. 

Cheyne, John, M.D. F.R.S.E. M.R.I.A. Phy- 
sician-General to the Forces in Ireland, &c. 

Croup. 

Epilepsy. 

Fever, epidemic gastric. 

Laryngitis. 

Wakefulness. 

Christison, Robert, M.D. Sec. R.S.E. Pro- 
fessor of Materia Medica and Therapeutics 
in the University of Edinburgh, &c. 

Latent diseases. 

Clark, Sir James, M.D. F.R.S. Physician to 
the Queen and Prince Albert, &c. 

Air, change of. 
Climate. 
Tubercular phthisis. 

Clutterbuck, Henry, M.D. Physician to the 
General Dispensary. 

Apoplexy, cerebral. 

Conolly, John, M.D. late Professor of Medi- 
cine in the London University, and Physi- 
cian to the Hanwell Lunatic Asylum. 

Alteratives. 

Disease. 

Hysteria. 

Medicine, practical, principles of. 

Corrigan, Dominick J., M.D. Physician to 
Jervis-Street Hospital, Dublin. 

Pemphigus. 
Plica Polonica. 
Rupia. 

Crampton, John, M.D. M.R.I.A. King's Pro- 
fessor of Materia Medica, Physician to Stee- 
ven's Hospital, &c. Dublin. 

Cyanosis. 

Diarrhoea, (with Dr. Forbes.) 

Crawford, Adair, M.D. Assistant Physician 
to the London Fever Hospital. 

Brain, inflammation of the substance of (Cere- 

britis). 
Coma. 

Convulsions. 
Inflammation, (with Dr. Tweedie.) 

Crawford, Andrew, M.D. Physician to the 
Hampshire County Hospital, Winchester. 

Bronchocele. 
Chorea. 

Cumin, William, M.D. Member of the Faculty 
of Physicians, Glasgow. 

Calculus, pathology and treatment. 

Cystitis. 

Dysuria. 

Incontinence of urine. 

Pityriasis. 

Psoriasis. 

Rickets. 

Scrofula. 

Sycosis. 

Oarwall, John, M.D. Physician to the Bir- 
mingham General Hospital. 

Anasarca. 

Artisans, diseases of. 

Ascites. 

Dropsy. 

Hydroperirardium. 

Hydrothora'* 

(Edema 



Duesbury, Frederick, M.D. Physician to 
the Dispensary, and to the Invalid Asylum, 
Stoke Newington. 

Transformations. 

Dunglison, Robley, Professor of the Institutes 
of Medicine in Jefferson Medical College, 
Philadelphia, and attending Physician to the 
Philadelphia Hospital. 
Besides the interstitial additions, the following articles : 

Acrodynia. 

Amentia, (with Dr. Marshall Hall.) 

Anthracion. 

Aphthse, (with Dr. A. Robertson.) 

Asphyxia of the newborn. 

Blood, morbid states of, (with Dr. M. Hall.) 

Bronchial Glands, diseases of the. 

Bronchitis, summer. 

Cachexia. 

Cholera infantum. 

Cirrhosis of the lung. 

Colon, torpor of the. 

Croup of the adult. 

Delirium tremens. 

Dengue. 

Diarrhoea, adipous. 

Disinfectant. 

Enteritis, (with Dr. Stokes.) 

Eutrophic. 

Fever, malignant remittent. 

Galvanism, (with Dr. Apjohn.) 

Glanders. 

Heart, polypus of the. 

Intussusception. 

Jaundice of the infant. 

Laryngitis, chronic. 

Milk-sickness. 

Mind, soundness and unsoundness of, (with Dr 
Prichard.) 

Molluscum. 

Nauseants. 

Ophthalmia, (with Dr. Jacob.) 

Palpitation, (with Dr. Hope.) 

Parturients. 

Ptyalism. 

Rheumatism, (with Dr. Barlow.) 

Sedatives, (with Dr. A. T. Thomson.) 

Spermatorrhoea. 

Spleen, diseases of the, (with Dr. Bigsby.) 

Statistics, medical, (with Dr. Bisset Hawkins.) 

Stomatitis. 

Strophulus. 

Throat, diseases of the, (with Dr. Tweedie.) 

Toothach. 

Toxicology, (with Dr. jSpjohn.) 

Elliotson, John, M. D. F.R.S. Physician to 

St. Thomas's Hospital, and late Professor 

of Medicine in the London University. 

Acupuncture. 
Neuralgia. 

Forbes, John, M.D. F.R.S. Physician in ordi- 
nary to her Majesty's Household, &c. 

Abdomen. 

Angina pectoris. 

Asthma. 

Auscultation. 

Bathing. 

Chest, exploration of. 

Diarrhoea (with Dr. Crampton.) 

Feigned diseases, (with Drs. Scott and Marshall.) 

Gillkrest, J., M.D. Deputy Inspector-Gene- 
ral of Hospitals, London. 
Fever, yellow. 

Goldie, George, M.D. Shrewsbury, late Phy- 
sician to the York County Hospital. 

Hrcmatemesis. 

Melrena. 

Purpura. 

Urine, bloody. (Hematuria.; 

Grant, James, M.D. Jedburgh. 

Nyctalopia. 



LIST OF CONTRIBUTORS. 



XV 



Gregory, George, M.D. Physician to the 
Small -pox Hospital. 

Chicken-pox. 
Small-pox. 
Vaccination. 
Varicella. 

Hall, Marshall, M.D. F.R.S. L. & E. &c. 

Abstinence. 

Anaemia. 

Blood, morbid states of. 

Bloodletting. 

Chlorosis. 

Diagnosis. 

Puerperal diseases. 

Symptomatology. 

Hancock, Thomas, M.D. Liverpool. 

Endemic diseases. 

Epidemics. 

Influenza. 

Hastings, Charles, M.D. Physician to the 
Worcester Infirmary, &c. 

Constipation, (with Dr. Streeten.) 

Hawkins, Bisset, M.D. F.R.S. Professor of 
Materia Medica and Therapeutics in King's 
College, London. 

Statistics, medical. 

Hope, J., M.D. F.R.S. Assistant Physician to 
St. George's Hospital, London. 

Aorta, aneurism of. 

Arteritis. 

Dilatation of the heart. 

Heart, diseases of the. 

Heart, fatty and greasy degenerations of. 

Heart, diseases of the valves of the. 

Heart, hypertrophy of the. 

Palpitation. 

Pericarditis and carditis. 

Houghton, James, M.D. Physician to the 
South-Eastern Dispensary, Dublin. 

Lepra. 

Lichen. 

Noli me tangcre, or Lupus. 

Pneumothorax. 

Scabies. 

Urticaria. 

Stomach, organic diseases of. 

Jacob, Arthur, M.D. M.R.I.A. Professor of 
Anatomy to the Royal College of Surgeons 
in Ireland. 

Amaurosis 
Ophthalmia. 

Johnson, Charles, M.D. Professor of Mid- 
wifery to the Royal College of Surgeons in 
Ireland. 

Hooping-cough. 

Joy, William Bruce, M.D. Fellow of the 
King and Queen's College of Physicians in 
Ireland, and Physician to the Dublin Gene- 
ral Dispensary. 

Catalepsy. 

Dentition, disorders of. 

Eczema. 

Elephantiasis Graecorum. 

Erythema. 

Fever, infantile remittent. 

Glottis, spasm of the. 

Hydrocephalus. 

Tabes mesenterica. 

Worms. 

Kay, J. P., M.D. Physician to the Ardwick 
and Ancoats Dispensary, Manchester. 

Transfusion. 



Kerr, William, M.D. Physician to the North- 
ampton General Infirmary. 



Epistaxis. 

Fungus h;ematodes. 

Glossitis. 

Hydatids. 

Parotitis. 

Pellagra. 

Pyrosis. 

Scorbutus. 

Tympanites. 

Yaws. 



Law, Robert, M.D. Fellow of the King and 
Queen's College in Ireland, Physician Ex- 
traordinary to Sir Patrick Dun's Hospital. 

Haemoptysis. 
Pleurisy, pleuritis. 

Lee, Robert, M.D. F.R.S. Physician to the 
British Lying-in Hospital, London. 

Abortion. 

Fever, puerperal. 

Ovaria, diseases of the. 

Phlegmasia dolens. 

Uterus and its appendages, pathology of the. 

Veins, diseases of the. 

Locock, Charles,M.D. Physician-accoucheur 
to the Queen, Physician to the Westminster 
General Lying-in Hospital, &c. 

Amenorrhoea. 
Convulsions, infantile. 
Convulsions, puerperal. 
Dysmenorrhcea. 
Lactation. 
Leucorrhcea. 
Menorrhagia. 
Menstruation, pathology of. 

MacAdam, David H., M.D. Physician to the 
South-Eastern General Dispensary, Dublin. 

Peritonitis, (with Dr. Stokes.) 

Montgomery, William F., M.D. Fellow and 
Professor of Midwifery, to the King and 
Queen's College of Physicians in Ireland. 

Identity, personal. 

Pregnancy and delivery, signs of. 

Rubeola. 

Succession of inheritance. — Legitimacy. 

Paris, J. A., M.D. F.R.S. President of the 
Royal College of Physicians, London. 
Dietetics. 

Prichard, J. C, M.D. F.R.S. Physician to the 
Infirmary and to St. Peter's Hospital, Bristol. 

Delirium. 

Hypochondriasis. 

Insanity. 

Somnambulism and animal magnetism. 

Mind, soundness and unsoundness of. 

Temperament. 

Quain, Jones, M.D. Professor of Anatomy 
and Physiology in the London University. 

Brain, inflammation of the membranes of, (Me- 
ningitis.) 

Robertson, Archibald, M.D. Physician to 
the Northampton General Infirmary. 

Aphonia. 
Aphthae. 

Roget, P. M., M.D. Sec. R.S. Consulting 
Physician to the Queen Charlotte's Lying- 
in Hospital, and to the Northern Dispensary, 
&c. 

Age. 
Asphyxia. 



XVI 



LIST OF CONTRIBUTORS. 



Scott, John, M.D. Edinburgh. 

Barbiers. 
Beriberi. 

Elephantiasis Araburn. 

Feigned diseases, (with Drs. Forbes and Mar- 
shall.) 

Stokes, William, M.D. Physician to the 
Meath Hospital, Dublin. 

Derivation. 

Dysphagia. 

Enteritis. 

Gastritis. 

Gastro-enteritis. 

Liver, inflammation of. 

Peritonitis, (with Dr. Macadam.) 

Streeten, Robert J. N., M.D. Physician to 
the Worcester Dispensary. 

Constipation, (with Dr. Hastings.) 

Symonds, J. A., M.D. Physician to the Gene- 
ral Hospital, Bristol. 
Tetanus. 

Thomson, A. T., M.D. F.L.S. Professor of 
Materia Medica and Therapeutics in the 
London University. 

Anthelmintics. 

Antispasmodics. 

Astringents. 

Cathartics. 

Diaphoretics. 

Diuretics. 

Emetics. 

Emmenagogues. 

Expectorants. 

Favus. 

Herpes. 

Ichthyosis. 

Impetigo. 

Narcotics. 

Refrigerants. 

Sedatives. 

Stimulants. 

Porrigo. 

Prurigo. 

Tonics. 

Thomson, Thomas, M.D. F.R.S. L. & E. 

Regius Professor of Chemistry in the Uni- 
versity of Glasgow, &c. 

Calculus, (chemical composition.) 
Waters, mineral. 

Todd, T. J., M.D. Physician to the Dispen- 
sary, Brighton. 

Achor. 

Acne. 

Alopecia. 

Bulls. 

Ecthyma. 

Ephelis. 

Indigestion. 



Todd, Robert B., M.D. F.R.S. Professor of 
Physiology and General Anatomy, Kings 
College, London. 

Paralysis. 

Pseudo-morbid appearances. 

Suppuration. 

Spinal marrow, diseases of. 

Townsend, Richard, M.D. M.R.I.A. Fellow 
of the King and Queen's College of Phy- 
sicians, Dublin. 

Apoplexy, pulmonary. 

Atrophy. 

Emphysema. 

Emphysema of the lungs. 

Empyema. 

Heart, displacement of. 

Hypertrophy. 

Rupture of the heart. 

Tweedie, Alexander, M.D. F.R.S. Physician 
to the London Fever Hospital, and to the 
Foundling Hospital. 

Abscess. 

Colic (with Dr. Whiting.) 

Convalescence. 

Erysipelas. 

Exanthemata. 

Fever, continued. 

Inflammation, (with Dr. Adair Crawford.) 

Miliaria. 

Roseola. 

Scarlatina. 

Throat, diseases of the. 

Venables, R., M.D. London. 

Liver, diseases of. 

Watson, Thomas, M.D. Physician to the 
Middlesex Hospital, &c. 
Hemorrhage. 

Whiting, John, M.D. Physician to the Surrey 
Dispensary, &c. 

Anodynes. 

Cold. 

Colic, (with Dr. Tweedie.) 

Colica Pictonum. 

Williams, Charles J. B., M.D. F.R.S. Pro 
fessor of Medicine in University College, 
London. 

Bronchitis. 

Catarrh. 

Coryza. 

Counter-irritation. 

Dyspncea. 

Expectoration. 

Incubus. 

Irritation. 

Malformations of the heart. 

Obesity. 

Pneumonia. 

Stethoscope. 



CONTENTS OE THE EIEST VOLUME. 



Contributors. Page 

Abdomen, Exploration of.Dr. Forbes 25 



Abortion , 
Abscess . . . 
Abstinence. 

Achor 

Vcne 



Lee 33 

Tweedie 36 

M. Hall 42 

Todd 45 

Todd 46 



Acrodynia Dunglison . 



Acupuncture 

Age 

Air, Change of 

Alopecia 

Alteratives 
Amaurosis 
Amenorrhcea . . 



Anaemia 

Anasarca 

Angina Pectoris 



54 

Elliot son 54 

Roget 57 

Clark 67 

Todd 71 

Conolly 74 

Jacob 78 

Locock 89 

M. Hall... 
Dunglison . 

Darwall 95 

Forbes 103 



92 



Anodynes Whiting 117 

Anthelmintics A. T. Thomson. 119 

Anthracion Dunglison. . . . . 122 

Antiphlogistic Regimen. Barlow 122 

Antispasmodics A. T. Thomson . 124 

Aorta, Aneurism of. . . . Hope 126 

Aphonia Robertson 139 

a v.u C Robertson ...'}, . n 

Aphthae ■? ~ .. C 140 

r £ Dunglison. . . 5 

Apoplexy, (Cerebral) . . Clutterbuck . . . 142 

Apoplexy, (Pulmonary) Townsend 155 

Arteritis Hope 163 

Artisans, Diseases of . . . Darwall 170 

Ascites Darwall 182 

Asphyxia Roget 188 

Asphyxia of the newborn Dunglison 205 

Asthma Forbes 206 

Astringents A. T. Thomson .229 

Atrophy Townsend 234 

Auscultation Forbes 237 

Barbiers Scott 264 

Bathing Forbes 266 

Beriberi Scott 287 

Blood, determination of Barlow 290 

Blood, Morbid States c Marshall Hall 

of ?_ Dunglison ... 

Bloodletting Marshall Hall. . 296 



291 



301 



Chicken-Pox Dr, 

Chlorosis 

Cholera 

Cholera Infantum 

Chorea 

Cirrhosis of the Lung . 

Climate 

Cold 

Colic 



Colica Pictonum 

Colon, torpor of the . . . 

Coma 

Combustion, Spontane- 
ous Human 

Congestion of Blood. . . 

Constipation 



Brain, Inflammation C Quain 

of C Adair Crawford 

Bronchial Glands, Dis- 
ease of the , . . Dunglison 331 

BronchM. { ^Zi^S. 

" Summer Dunglison 342 

Bronchocele And. Crawford.34:3 

Bullae Todd 352 

Cachexia Dunglison 353 

Calculi Thos. Thomson . 354 

Calculous Diseases Thos. Thomson. 365 

Catalepsy Joy 378 

Catarrh Williams 382 

Cathartics A. T. Thomson . 385 

Chest, Exploration of . . Forbes 391 



Contagion 

Convalescence 

Convulsions 

Convulsions, Infantile. . 
Convulsions, Puerperal. 

Coryza 

Counter-Irritation 

Croup 

Croup of the adult .... 

Cyanosis 

Cystitis 

Dead, persons found... . 
Delirium 

Delirium Tremens. . . < 

Dengue 

Dentition, Disorders of . 

Derivation 

Diabetes 

Diagnosis 

Diaphoretics 

Diarrhoea < 

Diarrhoea, adipous 

Dietetics 

Disease 

Disinfectant 

Disinfection 

Diuretics 

Dropsy 

Dysentery 

Dysmenorrhcea 

Dysphagia 

Dyspnoea 

Dysuria 

Ecthyma 

Eczema 

Education, Physical .. . . 

Electricity 

Elephantiasis Arabum. . 
Elephantiasis Grsacorum 

Emetics 

; Emmenagogues 



Contributors. Page 

Gregory 395 

M.Hall 396 

Brown 399 

Dunglison 426 

And. Crawford All 

Dunglison 440 

Clark 440 

Whiting 453 

Whiting.... ^ 

Tweedie 5 

Whiting 463 

Dunglison 466 

Adair CrawfordA66 

Apjohn 470 

Barlow 476 

Hastings ? ^ 

Streeten 5 

Brown 500 

Tweedie 505 

Adair Crawford.508 

Locock 519 

Locock 522 

Williams 524 

Williams 526 

Cheyne 534 

Dunglison 542 

Crampton 542 

Cumin 545 

Beatty 548 

Prichard 582 

Carter 7 5g7 

Dunglison ... 5 

Dunglison 594 

Joy 595 

Stokes 601 

Bardsley 606 

Hall 625 

A. T. Thomson. 626 
Crampton...^^ 

Forbes 3 

Dunglison .... 642 

Paris 642 

Conolly 674 

Dunglison 689 

Brown 690 

A. T. Thomson. 695 

Darwall 701 

Brown 720 

Locock 728 

Stokes 730 

Williams 732 

Cumin 734 

Todd 737 

Joy 743 

Barlow 750 

Apjohn 765 

Scott 770 

Joy 773 

A. T. Thomson. 776 

A. T Thomson. 784 

(xvii) 



THE 



CYCLOPAEDIA 



OP 



PRACTICAL MEDICINE. 



ABDOMEN (Exploration of the) It is 

intended, in the present article, to give a brief 
account of the different methods employed by 
physicians for exploring, or physically examining, 
the external parts of the abdomen, with the view 
of discovering or discriminating the diseases of the 
viscera contained in this cavity. The term here 
adopted to designate the application . of these 
methods (from the verb exploro, to examine), 
although long received into our language, has been 
only very recently used in medicine in its present 
?ense : it has been borrowed from the pathologi- 
cal writings of the French. In many parts of the 
present work occasion will be found of pointing 
out the paramount importance to the practitioner 
of a minute and accurate diagnosis of diseases, and 
of stating, in detail, the various methods in use for 
acquiring this knowledge. Of these methods none 
are so certain in their results, and, consequently, 
so satisfactory to the mind, as those which are 
based on what are termed physical signs of dis- 
ease, in contradistinction to the more common 
class of rational or sympathetic signs which are 
derived from the more variable phenomena of dis- 
ease termed symptoms. It is with the physical 
signs of diseases that exploration, in the sense in 
which we shall employ it, has to do ; and in the 
present article it is intended to restrict its use to a 
part only of the physical signs by which abdomi- 
nal diseases are distinguished. t 

Physicians are often much too negligent in 
examining the external parts of the body in inter- 
nal diseases. From inadvertence, carelessness, or 
mistaken delicacy, they thus deprive themselves 
of the simplest, readiest, and surest means of re- 
cognising many important affections. This remark 
applies chiefly to the diseases of the abdomen and 
chest, some of which are strikingly expressed, if 
we may so speak, on the surface — either in a per- 
manent change of configuration, or in a temporary 
alteration of the natural movements, or both. Such 
important physiognomical diagnostics can only be 
obtained (except in rare cases) by uncovering the 
body ; and they can, in general, be immediately 
obtained by doing so. It happens constantly to 
th >se who are accustomed to examine the surface 
of the body in internal affections, to meet with 
examples of important diseases being mistaken or 
overlooked, merely because this simple proceeding 
had been neglected by the practitioner. One of 
the most common cases of this kind is chronic 
pleurisy, the presence of which is often detected 
by a single glance at the naked chest j one side 
being found to be immovable, and either con- 
Voi. I 4 p 



traded or enlarged beyond the limits of the healthv 
state. Superficial inflammations of the parietes 
of the chest and abdomen have been treated a« 
phlegmasia? of the viscera in persons who had no 
desire to conceal their complaints ; while others, 
from unwillingness to admit the existence of local 
eruptions on the skin, have equally deceived their 
medical attendants. It is obvious that such mis- 
takes could not happen to those who are accus- 
tomed to examine the exterior parts of the body ; 
and it will not be denied that, whenever they do 
happen, they must tend to lower the character of 
the practitioner in the eyes of his patient. Such 
mistakes are much more liable to be made respecting 
females than males, partly on account of the greater 
delicacy respecting examination entertained by 
the physician in the case of the former, and partly 
owing to the greater obstacles to examination from 
the peculiar nature of their dress. 

It will not, we trust, be imagined, from the 
above remarks, that the writer wishes to recom- 
mend the examination of the naked chest or ab- 
domen in every case of alleged disease in these 
cavities. In most instances, even when a minute 
investigation is required, it is unnecessary to 
remove the under garment ; and in the case of 
females this is never to be done if it can be avoided. 
In some cases, no doubt, it may be expedient to 
apply the hand to the skin, and even to inspect it 
freed from all covering ; but in the case of females 
more particularly, neither should be had recourse 
to, unless an accurate diagnosis cannot be other 
wise obtained. 

If physical examination is of such general im- 
portance as a means of diagnosis, it is especially 
so in the diseases of the abdominal cavity. The 
great number and importance of the organs con- 
tained in it, render its diseases proportionally 
numerous and important ; while the proximity 
and intermixture of some of the organs, and the 
variable site of others, render their symptoms 
complex and multifarious, and their diagnosis 
consequently difficult. On the other hand, the 
abdomen, from its anatomical structure, seems at 
first sight to promise much greater facilities for 
the employment of physical diagnosis than eithei 
of the two other great cavities of the bodv. It> 
soft and yielding walls at once invite and admt 
of such examinations of the parts within as appeal 
to be altogether forbidden by the inflexible bonj 
defences of the others. It will, however, be seen 
hereafter, that, in regard to the cr>°st, this supen 
ority of the abdomen is only apparent in as far u» 
relates to the certainty of the results ; although \S 

(25) 



26 



ABDOMEN, (EXPLORATION OF THE) 



is undoubtedly real in respect of the directness 
and obviousness of the methods of exploration 
which are applicable to it. 

Previously to describing these methods, it is 
necessary to notice the topographical relations of 
the exterior surface of the abdomen to the parts 
within. This kind of knowledge is of the great- 
est importance to the practical physician in regard 
to many parts of the body, but more particularly 
the chest and abdomen. Without it he will con- 
stantly be left in doubt respecting the parts affected 
with disease, and will frequently be led into the 
error of attributing the symptoms of one suffering 
organ to another. With the view of facilitating 
the acquisition of knowledge of so much value, 
and of enabling the practitioner accurately to 
record his own observations, and to communicate 
to others precise information respecting the seat 
and signs of internal diseases, it has been custom- 
ary to map out the exterior surface of the chest 
and abdomen into different compartments, termed 
regions, by means of imaginary lines described 
upon it, corresponding with imaginary planes 
passing to the centre of the body. These lines 
have not always been drawn in the same manner : 
on the contrary, there has ever existed great dis- 
crepancy among the writers and teachers of this 
and other countries respecting the number, the 
extent, and the names of the regions. This is a 
circumstance greatly to be regretted ; and it is 
much to be desired that some arrangement could 
be pioposed which might attain general assent 
from teachers and practical writers. It is probable 
that no plan can be proposed that is without even 
obvious defects ; but it would be greatly for the 
benefit of the student and the practitioner if there 
were a fixed plan of any kind, owe plan universally 
adopted, even if defective in some of its parts. At 
present hardly any two teachers or writers adhere 
to the same division or nomenclature. 

In the annexed regional plans of the trunk of 
the body, (designed and executed by Mr. Paxton, 
of Oxford,) the nomenclature and divisions most 
generally adopted have been as much as possible 
adhered to ; but it was occasionally found neces- 
sary to differ in both these points, in order to 
attain what appeared to be objects of practical 
importance. We have gone upon the fundamen- 
tal principle of defining every region accurately, in 
every individual case, by drawing all the lines 
perfectly straight, and between points that are at 
once fixed in their nature and obvious to the 
senses. By these means there can never be any 
doubt as to the intended place or extent of par- 
ticular regions, whatever objections may be raised 
against the propriety of the divisions. As it was 
found advisable to extend the same vertical lines 
over the two great cavities of the trunk, we are 
under the necessity of introducing the diagrams 
of the chest in conjunction with those of the ab- 
domen, in order to point out the fixed points from 
which the lines are drawn. We shall only, how- 
ever, in this place, take notice of the abdominal 
-egions, which, it will be seen, are quite distinct 
from those of the chest. 

The various regions are, as we have said, 
Dounded by straight lines, or rather by direct lines 
drawn between fixed points, on a rounded or 
uneven surface. The vertical lines which have 
reference to the abdomen arc five in number, and 
run as follows: 1. from the external tubercle of 



the pubes (or insertion of Poupart's ligament) to 
the acromial extremity of the clavicle (right and 
left side); 2. from the posterior boundary of the 
axilla (or inferior edge of the latissimus dorsi) to 
that point of the crest of the ilium, on which it 
falls vertically (right and left side); 3. along the 
spinous processes of the vertebra from the sacrum 
to the nape of the neck. The transverse lines are 
four in number, and are drawn exactly in horizon- 
tal planes, as follows: — l.on the point of the 
xiphoid cartilage ; 2. on the last short rib ; 3. on 
the anterior and superior spinous process of the 
ilium on each side ; 4. on the upper margin of the 
os pubis. We have thus three horizontal and 
five vertical bands, and thirteen regions in all ; of 
which five may be termed anterior, four lateral 
(two on each side), and four posterior. Their 
names are as follows : — anterior regions, epigas- 
tric, umbilical, hypogastric, inguinal (right and 
left) ; lateral regions, hypochondriac (right and 
left), iliac (right and left) ; posterior regions, in- 
ferior dorsal (right and left), lumbar (right and 
left). W T e have not carried the subdivision of the 
inferior zone to the posterior and lateral parts of 
the. trunk ; because the parietes there are of such 
a nature as to prevent us from deriving any aid 
in the investigation of the subjacent parts from 
exploration. 

There are few more useful exercises for the 
anatomical student than endeavouring to imprint 
on his mind some plan of this kind, and to teach 
himself by observation, and by multiplied expeu- 
ment on the dead subject, the precise relations of 
the regions to the viscera that lie beneath them 
He ought always to consider his knowledge a9 

Fie. 1. 




ABDOMEN, (EXPLORATION OF THE) 
Fig. 2. Fig. 3. 




EXPLANATION OF THE FIGURES. 



Abdominal Regions. 



4. Epigastric. 

5. Umbilical. 

6. Hypogastric. 

9. Hypochondriac. 



1. Humoral. 

2. Subclavian 

3. Mammary. 
7. Axillary. 



10. Iliac. 

11. Inguinal. 

15. Inferior Dorsal. 
10. Lumbar. 



Thoracic Regions. 



imperfect, until he is able to state, with conside- 
rable accuracy, the organs, or parts of organs, that 
will be wounded by a stiletto thrust in at any 
point. It is only after possessing such a degree 
of knowledge, that he can enter, with full advan- 
tage, upon the study of the various methods of 
exploration which we are now about to detail, or 
that he can expect to derive from them the great 
practical benefits which they are calculated to 
supply. 

The methods of exploring the abdomen may be 
reduced to three — inspection, manual examina- 
tion (or palpation}, and percussion. We shall 
notice them in order. 

T. Inspection. This term is here used in its 
(Amplest sense, as restricted to the operations of 
sight only. 

By inspection we judge of the size, form, and 
movements of the abdomen. The two last-named 
conditions arc, perhaps, better ascertained by this 
than by any of the other forms of exploration. It 
is needless to point out in how many instances 



8. Subaxillary or Lateral. 

12. Scapular. 

13. Interscapular. 

14. Superior Dorsal or Subscapular. 

our judgments respecting the nature of diseases, a» 
derived from other signs, are modified by the size* 
of the abdomen. This is an important diagnostic 
sign in many diseases, both acute and chronic, 
more particularly perhaps in the diseases of in- 
fants ; and it is often equally valuable as aiding 
prognosis, especially in fevers and other acute 
diseases. 

The mere form of the abdomen, independently 
of its size, is no less valuable as a sign, in many 
cases. By this alone we are sometimes enabled 
to form a probable conjecture, if not to decide al 
once, respecting the scat and nature of a disease ; 
although a practitioner could not be justified in 
acting upon such knowledge without having re- 
course to other signs and other modes of exploia 
tion. In pregnancy, in ovarian dropsy, in ascites, 
tympanites, and enlargements of the liver, the 
form of the aodomen is different. In certain cases, 
the direction of the inferior border of the rib* 
assists us in determining whether enlargements 
of the epigastric and hypochondriac regions ori<f- 



28 



ABDOMEN, (EXPLORATION OF THE) 



nate in the abdomen or within the chest. In the 
former ease, we may expect the border of the ribs 
to be turned outwards ; in the latter, inwards, with, 
probably, a bulging out of the ribs above this 
point. In sonic examples of enteritis and colica 
pictonum, the nature of the pain is very similar; 
but the form and size of the abdomen are often very' 
different, and sufficient to discriminate the two 
diseases. In the one the abdomen is distended, in 
the otber contracted. In some of the severer 
febrile affections of children, the form and size of 
the abdomen afford valuable signs to assist us in 
determining a question frequently of great diffi- 
culty, viz. whether the principal seat of the disease 
is in the internal mucous membrane or in the 
brain. 

The movements of the abdominal parietes are 
equally worthy the practitioner's attention. In 
many cases, these movements are characteristic 
of particular morbid states, and very considerably 
assist diagnosis, more especially when viewed 
together with the motions of the thorax. In peri- 
tonitis, enteritis, and other inflammatory diseases 
of the abdomen, likewise in great distension of the 
cavity from dropsy, pregancy, tumours, &c. &c. 
the parietes frequently remain motionless during 
respiration, while the movements of the chest are 
proportionally increased. The reverse obtains in 
analogous affections of the thoracic viscera. In 
cases in which both sides of the chest are rendered 
immovable by pain or physical incapacity, the 
abdominal movements are often increased to a 
remarkable extent. This is particularly observed 
in the case of double pleurisy, and also in asthma. 
In the paroxysms of this last affection, however, 
the form and movements of the abdomen are very 
different from those observed in the former. In 
asthma, the walls of the chest and the diaphragm 
are forcibly retracted, and cling to the imperfectly 
expanded lungs ; the abdominal muscles are also 
drawn in towards the diaphragm, but are at the 
same time forced into violent yet very limited 
action. 

II. Manual examination, or palpation.* 
By the simple touch, or application of the hand 
without pressure, we judge of the size, form, de- 
gree of sensibility, and temperature, of the exter- 
nal walls of the abdomen ; and by touch, combined 
with pressure, (palpation,) we attempt to ascertain 
yet more accurately the condition of the internal 
organs. For the performance of the former part 
of the process, no other position of the patient is 
requisite but that which permits the free access of 
the hand to the surface of the abdomen ; but for 
the successful exploration of the internal parts, it 
becomes necessary that the patient should assume 
that posture which is most favourable for the 
relaxation of the abdominal muscles. This result 
is best obtained when the patient is laid on the 
back, with the head moderately raised and bent 
forwards on the breast, the arms extended by the 
sides, the thighs bent nearly at right angles on the 
trunk, the knees apart and turned outwards, and 
the feet resting on the bed in contact with each 
other. When so placed, the patient should be 
made to understand that he is to exert as little 
muscular effort as possible in retaining his posi- 
tion ; and we are to take care that such exertion 



* " Palpation, the act of feeling."— Johnson. From 
r«/pi», or paipor— palpatio. 



is not forced upon him by any proceeding of ours 
which can be avoided. Sometimes the mere cold- 
ness of the hand, or even the simple touch, has 
the effect of throwing the abdominal muscles into 
action. Apprehension of pain from pressure has 
the same effect ; and, likewise, misapprehension 
of our wishes respecting the condition of the ab- 
dominal parietes. In such cases we shall gene- 
rally find, after a short time, that the muscles 
relax gradually of their own accord, particularly 
if the patient's attention is diverted from our pro- 
ceedings ; or we succeed in our object by causing 
the individual to take a deep inspiration, to cough, 
or speak ; by which means the state of tonic 
tension of the muscles is destroyed. Sometimes, 
however, we find it impossible to obtain a com- 
plete relaxation ; and this circumstance is of itself 
an important sign, and taken in conjunction with 
others is well deserving the attention of the prac- 
titioner. The patient, in these cases, seems in- 
stinctively to keep the muscles in a state of tension, 
in order to ward off the pressure from the parts 
beneath, some of which are inflamed, and there- 
fore morbidly sensible. This state of the muscles 
is often found in inflammation of the intestinal 
mucous membrane. 

It is of the more consequence to ensure the 
complete relaxation of the muscles, because their 
tension not merely prevents the accurate examina- 
tion of the parts beneath, but even occasions the 
muscles themselves to be mistaken for enlarge- 
ment or induration of the viscera. This remark 
applies more particularly to the recti muscles, the 
prominent bellies of which sometimes simulate 
pretty accurately the inferior border of an enlarged 
liver. We have often seen this mistake com- 
mitted at the first moment of exploration ; and, 
although generally, it has not always been cor- 
rected by further examination. 

The chief objects we have in view, in exploring 
the abdomen, are the following : — To ascertain, 
1, its form and size; 2, its degree of tension or 
solidity ; 3, its temperature ; 4, its sensibility ; 
5, the presence or absence of tumours of the 
viscera, or new growths within the cavity ; G, the 
presence of fluids in the peritoneal sac ; 7, the 
nature and extent of the intestinal contents, &c. 
Some of these require much more attention than 
others. We shall only notice, with any degree 
of minuteness, such of them as are of most im- 
portance. 

The form, size, degree of temperature, tension 
and superficial sensibility of the abdomen, are 
ascertained by the simple application of the hand 
to the different parts of it in succession, or, at 
most, by the gentlest pressure. Some precautions, 
however, and some further attention, are requisite, 
in order to enable us to ascertain the true degree 
of temperature and sensibility of the parts. 

Owing to the singular infidelity of our sensa- 
tions as a measure of temperature, the greatest 
care is necessary to prevent our being misled in 
judging of the degree of heat from the testimony 
of our hands alone. Every body knows that out 
perceptions of warmth have relation as much to 
the preceding as to the actual sensation. We are 
apt to consider a body as warm, soiely because it 
is of superior temperature to one previously 
touched ; and we may almost immediately be 
induced to reckon the very same substance cold 
after touching one that is of a temperature greatly 



ABDOMEN, (EXPLORATION OF THE; 



29 



higher. The temperature of the hand itself is I 
also to be taken into account, and not merely its 
actual temperature, but its habitual temperature. 
Some persons have hands habitually cold, and 
others habitually warm ; and it is not likely that 
such persons will judge similarly of temperature, 
even when their hands chance to be equally warm 
at the period of experiment. It is still less likely 
that they will agree if their hands are of different 
temperature. In examining the temperature of 
the abdomen, or of any other part of the body, it 
will be most, safe to judge< rather of the relative 
than of the absolute degree of heat ; and this will 
be best done by examining alternately other parts 
of the body presumed to be in a state of health.* 

The temperature of the abdominal surface is 
frequently an important sign of disease. If very 
elevated, it indicates inflammation of the subjacent 
parts, or, at least, that increased afflux of blood, 
which cannot be practically discriminated from 
the early stage of inflammation. If that singular, 
and, we believe, still unexplained pungency, which 
attends certain febrile and inflammatory affections, 
is present, the complication renders the sign still 
more significant of severe disease. 

In exploring the degree of sensibility, the pres- 
sure should, of course, in the first place, be made 
in the gentlest manner, and with the open hand. 
If the surface is impatient of the slightest touch, 
we may be assured that the cause of the tender- 
ness is in the parietes. If no superficial tender- 
ness exists, we proceed to examine the parts more 
freely by compressing the parietes more or less 
forcihly, and in different directions. Sometimes 
we find that a change in the direction of the pres- 
sure produces very different results in the same 
part. In peritonitis, for instance, direct downward 
pressure towards the spine is sometimes borne 
tolerably well, when pressure in a lateral direction, 
particularly such as forces the abdominal peritone- 
um to slide over the intestines, occasions extreme 
pain. In chronic diseases, much greater freedom 
may generally be used in our explorations ; and 
when considerable doubt exists respecting the 
nature of a disease, we should endeavour to bring 
every organ of the abdominal cavity within the 
sphere of our explorations. 

Some physicians, in exploring the abdomen, 
seem to consider it sufficient merely to pass the 
hand across it once or twice, using a very gentle 
pressure in the suspected places. Such a method 
is often more calculated to mislead than to instruct. 
It may, indeed, satisfy the patient that his case has 
met with due attention, while he has, at the same 
time, been treated with gentleness and delicacy ; 
but it cannot be satisfactory to the practitioner who 
knows the value of this mode of investigating dis- 
ease. But while we recommend the propriety of 
a free exploration, it is necessary to caution the 
young practitioner against adopting one of unne- 
cessary violence. Some physicians make use of 
so much pressure, or rather they apply it in so 
injudicious a manner, that they hardly ever fail to 
elicit from the patient the expression of pain in 
the suspected region. This is particularly the 
case when the pressure is made, with the very 

* Nothing run show the imperfection of mere sen- 
sation as a test of temperature, more strongly than the 
fact constantly observed, of patients am] their attendants 
reporting particular parts aapreternaturallyhot— " burn- 
ing hut," —which arc found on trial, to be of the natural 
degree of warmth. 



points, or still more with the nails of the fingers 
or when the soft parts are compressed against such 
as are solid. No very general rules can be laid 
down in such cases. Experience of the natural 
sensibility of the parts to pressure, in health and 
disease, can alone give the true practical tact ; but 
even experience, we find, may here, as in other 
circumstances, be over-mastered by the influence 
of theory and prejudice acting on a weak judgment 
or a warm imagination. In every case, while 
exploring the sensibility of the abdomen, it is im- 
portant to watch the expression of the patient's 
countenance ; as this is often found to be a truer 
index of his sensations than his words are. 

If, in the course of our exploration, we discover 
any unusual swelling or indurated part, we must 
endeavour to ascertain its nature and various 
relations, — its exact site, size, form, consistence, 
connexions, and degree of sensibility ; whether it 
contains a fluid or not, whether it is pulsatile or 
not, and whether it is fixed or movable. All these 
circumstances are of consequence. The situation, 
size, and form of the swelling will enable us to 
judge respecting the organ or part affected ; its 
consistence, degree of sensibility, &c. will help us 
to the knowledge of the nature of the tumour 
itself. In persons that are of a spare habit, and in 
whom the abdominal parietes are relaxed, and 
more particularly in women and children, whose 
muscles are naturally small and feeble, we are 
able to ascertain the condition of almost all the 
parts contained in the abdomen with considerable 
minuteness, and to an extent beyond what is 
commonly believed by practitioners. In many 
cases, for instance, it is easy to feel the mesenteric 
glands when enlarged, and even the kidneys. We 
must, however, be careful, in making these free 
examinations, not to mistake natural conditions 
of the parts for morbid deviations. Masses of in- 
durated faeces in the colon, and even the spinal 
column, have been mistaken for morbid growths. 
(Bianchi, Hist. Hspat. 325. Double, Semeiol. t. 
i. 383.) Errors of this kind may, in general, be 
avoided. The movableness of the fsecal masses 
ought to point out their nature ; and the extreme 
fixedness of the spine, as well as its form and 
direction, will hardly permit such a mistake to be 
committed by any one possessed of a common 
degree of anatomical knowledge. 

In examining the abdomen with the view of 
detecting fluids accumulated in its cavity, we, in 
some respect, reverse the preparatory steps recom- 
mended in searching for more solid matters. In 
exploring for fluids, we wish the abdominal parie- 
tes to be in a state of tension rather than relaxa- 
tion : and, with a view to obtain this result, if the 
patient is in bed, and cannot conveniently get up, 
we make him lie quite flat, with the head low and 
the legs extended ; or we even increase the ab- 
dominal tension still further by placing a pillow 
under the loins. It is, however, still better if the 
patient can be placed in the erect position ; as the 
abdominal walls are thereby rendered naturally 
tense, and the fluids are accumulated at the inferior 
and anterior parts of the cavity, in place of being 
intermixed with, and in some degree hidden by 
the intestines, as is partly the case when the 
patient is in the horizontal position. The litt.e 
manoeuvre for ascertaining the fluctuation of the 
fluid is universally known. It consists, simply, in 
placing the palm of one hand against one side of 



30 



ABDOMEN, (EXPLORATION OF THE) 



the abdomen, with a firm but gentle pressure, and 
tapping smartly with the other hand directly op- 
posite to it on the other side. If fluid is present, 
the impulse will be transmitted through it to the 
other hand, producing a peculiar vibratory shock 
which cannot be mistaken, after having been ex- 
perienced a certain number of times. The import 
of this fluctuation as a sign of disease is well 
known : it is almost pathognomonic of ascites, or 
dropsy of the peritoneum. It is, however, also 
found in other diseases of the abdomen ; and is 
generally acknowledged to be of importance, both 
positively and negatively, in aiding their diagnosis. 
For the various diseases in which it is employed 
as a sign, we refer to the different articles of this 
work, in which these diseases are treated. And we 
would here observe once for all, that in drawing 
up the present paper we have always had in view 
the ampler diagnosis which will be found under 
the head of individual diseases ; our object not 
being to establish the diagnosis of particular dis- 
eases, but to give the practitioner a general out- 
line of the methods of exploration which are more 
or less applicable to all the diseases of the abdomen. 

If this were the place for such disquisitions, it 
were easy to show, from the authority of the best 
practical authors of all ages, how very important 
a place in the diagnosis of diseases has been always 
assigned to the physical exploration of the abdo- 
men. In the early ages of physic, this practice 
was, from various circumstances, much more in 
use than afterwards. Subsequently to the discovery 
of the circulation of the blood, when so much 
reliance was placed on the indications of the pulse, 
and when men's minds were so much occupied by 
theoretical and metaphysical distinctions, the phy- 
sical investigation of diseases generally, and of 
those of the abdomen among the rest, fell into 
neglect. It has, however, during the last fifty 
years, and more especially during the present 
century, more than regained its pristine estimation 
with all well-informed physicians, and is at length 
secured from all future decadence on the immov- 
able basis of organic pathology. With good 
reason, therefore, we may conclude this imperfect 
exposition of the method of palpation, as applied 
to diseases of the abdomen, in the words of Hip- 
pocrates and Baglivi. " Certain it is that he who 
examines the abdomen, as well as the pulse, is 
much less likely to be deceived than he who does 
not."* " If physicians were always to examine 
the abdomen, upon first visiting the patient, more 
particularly in acute diseases, they would assuredly 
commit much fewer mistakes than they do at 
present, neglecting this method of exploration. 
The knowledge of the condition of the upper parts 
of the abdomen improves vastly both our treat- 
ment and our prognosis." j- 

III. Percussion. (From percussio — percutio 
— per and quatio.) This form of abdominal ex- 
ploration had been used as an occasional aid to 
diagnosis from very early times. The manoeuvre 
for detecting the fluctuation of liquids, mentioned 

* Deindc .|iii manibus contrectavit ventrem [ac venas], 
minus falli potest, quam qui non contrectavit. Hippoc. 
Predict., lib ii., § v. 

1 Si medici nostri temporia omnium epgrotorum liypo- 
chonriria statim tractarent, in morbis potissimura acutis, 
pauciores certS committerent errorea quam faciunt Bpreta 
bypochnndriorum observatione. Uui bene noverit hypo- 
chondriorum statum in morbis, quam bene curare nove- 
rit, quam bene praesagire ! Bagliii de Prax. Med., lib. 
ii. cap. 9 Op. p. 3i) 



under the last head, is a mode of percussion ; and 
the very name so long borne by one morbid con- 
dition of this cavity [tympanites, from rv^avov, 
a drum) is at once sufficient evidence of the prac- 
tice, and of its antiquity. It is only, however, of 
very recent date that any attempt has been made 
to establish a formal and elaborate system of dia- 
gnosis, applicable to diseases of the abdomen, by 
means of percussion. M. Piorry, a young Parisian 
physician, has the honour of having, if not in- 
vented, at least brought into a formal and matured 
shape, this new application of the discovery of 
Auenbrugger, and with practical results of greater 
precision and importance than could have been 
anticipated-! 

In the article Auscultation a full account 
will be given of the principles upon which per- 
cussion, as a general means of diagnosis, is founded. 
At present, nothing more will be attempted than 
a mere practical exposition of the method as 
applied to the discrimination of abdominal dis- 
eases. We shall only so far anticipate the details 
of the article referred to as to state that there are 
two methods of eliciting sounds from the surface 
of the body by percussion, with the view of judg- 
ing of the physical condition of the parts beneath, 
— the one termed direct percussion, or, simply, 
percussion ,- the other mediate percussion. The 
former is the proceeding proposed by the great 
discoverer of the method, Auenbrugger, and con- 
sists in simply striking the part in a particular 
manner, with the points of two or more fingers 
united ; the latter differs very little either in prin- 
ciple or practice, except that a thin plate of solid 
and elastic matter, as of wood or ivory, is inter- 
posed between the fingers and the surface of the 
body. In exploring the chest by means of per- 
cussion, the comparative solidity and elasticity of 
its walls, as well as the nature of its contents, 
tender the interposition of a sonorous body be- 
tween the fingers and its surface less necessary, 
although it will be seen that this is useful even 
there ; but in the case of the abdomen such assist- 
ance is absolutely necessary to the production of 
sufficient sound to enable us to judge of the con- 
dition of the viscera within. In the following 
observations it will, therefore, be understood that 
mediate percussion is the method always spoken 
of. The small ivory plate on which the percus- 
sion is made has been termed, by its inventor M. 
Piorry, the plcximeter, or measurer of percussion. 
In exploring the abdomen by this method, we 
make use of various degrees of force in applying 
the plate to the surface, so as to depress this more 
or less, according to the objects we have in view. 
In many cases percussion on the plate pressed 
slightly on the surface, yields a very different 
sound from that elicited from it in the very same 
spot, when it is pressed deeply into the cavity of 
the abdomen. In the former case, the sound may 
be perfectly tympanitic, owing to the proximity 
to the surface of the intestines containing air ; 
while in the latter it is often dull or dead, from 
the circumstance of the plate having been depressed 
below the level of the floating intestines into 
mediate contact with some solid or fluid body 
incapable of yielding similar sounds. 

| The two following works, by M. Piorry, are well 
worthy the reader's attention : — 

1. De la Percussion Mediate. Paris, 1828. 

2. Du Procedc Operatoire a suivre dans I'Exploration 
des Organes par la Percussion Mediate. Paris 1830 



ABDOMEN, (EXPLORATION OF THE) 



31 



In the following brief sketch of the results of 
abdominal percussion, we shall, in a great mea- 
sure, follow M. Piorry, referring the reader to his 
elaborate work for further information. It will 
scarcely be credited, by those who have never 
practised, nor seen practised, this method, to what 
a singular degree of minuteness of diagnosis M. 
Piorry has carried it. Such persons may proba- 
bly be disposed to consider many of his statements 
as founded in delusion, if not in fiction. But it 
may be well for them to recollect that the discove- 
ries of Laennec were so designated by many on 
their first promulgation ; while, at present, within 
the short period of a dozen years, only an insig- 
nificant minority call in question the truth of even 
the most remarkable of them. We do not pretend 
to have verified all the statements made by M. 
Piorry ; and, indeed, nothing short of the indomi- 
table zeal of a young Parisian pathologist of the 
present day could enable any one to do so within 
a moderate space of time ; but from our knowledge 
of the results that are obtained from percussion as 
applied to the chest, and from numerous trials of 
it in abdominal affections, since the publication of 
M. Piorry's first work, we entertain no doubt of 
the general accuracy of his conclusions. At the 
same time we must admit, that to reach such a 
nicety of acoustic tact as is implied in several of 
the results recorded by him, will require more 
leisure and continued application than most men 
engaged in practice can afford to give. But such 
a practical acquaintance with the method as will 
be found highly useful, may soon be acquired by 
any one ; and we consider it the duty of every 
practitioner to endeavour to acquire thus much at 
least. 

The position of the stomach relatively with the 
surface is well known. In general, it occupies the 
epigastric and left hypochondriac regions, its 
greater extremity occupying the latter, and its 
smaller extremity extending to the right side of 
the epigastric region, or even into the superior 
part of the right iliac. But its position varies 
extremely, according to its degree of fulness, and 
the condition of the neighbouring viscera. It 
varies also greatly in respect of its proximity to 
the abdominal parietes. In the great majority of 
cases, some part of its surface lies in immediate 
contact with the abdominal parietes, more espe- 
cially when it contains a considerable quantity of 
ingesta. When empty, or nearly empty, it some- 
times is retracted towards the spine, while the 
colon or ilium lies in the front of it. As the 
stomach very generally contains a considerable 
portion of air, percussion over its usual site com- 
monly yields a very clear sound. The clearness 
of this sound is found to be gradually diminished 
as food or drink is taken. When the stomach is 
filled to repletion, it yields nearly as dull a sound 
as the solid viscera. When it contains, at the 
same time, a considerable quantity both of air and 
liquid, percussion produces a peculiar sound, 
termed humoric by M. Piorry, and which has a 
sort of silvery, vibratory clearness, somewhat 
resembling the metallic tinkling of Laennec. 
This sound is observed in other parts of the 
abdomen, where there is an accumulation of air 
and liquid either in actual contact or in contisru- 
,>us cavities. It is not, however, peculiar to this 
condition of parts, being also found wherever the 
uir ia forced out of a large cavity through a small 



openh.f. The knowledge of the condition of the 
stomach, as to emptiness or repletion, and likewise 
as to the general quality of i,s contents when full, 
may be very useful in many cases, both in prac- 
tical medicine and in medical jurisprudence. 
When we know, from the history of the case, that 
the viscus is empty, or, at least, that it does not 
contain any food, a completely dull sound elicited 
from its usual site will indicate that some conside- 
rable morbid change has taken place either in it 
or the neighbouring parts. Its habitual tympany 
will be manifested by signs of an opposite kind. 

In the state of health, the large intestines almost 
always contain a very considerable quantity of 
air ; the small intestines generally contain some 
also. In consequence of this circumstance, per- 
cussion over their respective sites yields the tym- 
panitic sound in a greater or less degree, in pro- 
portion to their proximity to the surface, the size 
of the intestine, and quantity of air contained in 
it. The ccecum being one of the most fixed parts 
of the intestinal canal, and generally containing a 
considerable quantity of gas, renders the right iliac 
region usually sonorous in the state of health. 
From this point we can also, in general, trace the 
transverse arch of the colon, by means of a tract 
of clearer sound across the upper part of the um- 
bilical region to the left iliac region. It is well 
known how constantly this intestine contains a 
large quantity of air. The left iliac region gene- 
rally yields a duller sound than the right, but not 
always ; the result being dependent on the parti- 
cular portion of intestine lodged there, and the 
state of its contents. The sigmoid flexure, which 
most commonly occupies this region, contains, in 
general, more fecal matter than the ccecum or the 
transverse arch of the colon, and therefore yields 
a duller sound. 

The small intestines usually occupy the greater 
part of the centre of the abdomen, filling the 
umbilical region, and encroaching, more or less, 
upon all the adjacent regions. They may be said 
to be, in a considerable degree, surrounded by the 
colon. They generally contain some air in the 
state of health ; but a great deal less in proportion 
to their size and other fecal contents, than the 
large intestines : they, therefore, yield much less 
sound on percussion. When they contain very 
little air and much chymous fluid, they hardly 
give any of the tympanitic resonance. This 
natural dulness is sometimes increased by disease 
within the bowel, but it is, we believe, much more 
frequently diminished. The increased dulness in 
the regions occupied by the sonorous portions of 
the intestines is most commonly occasioned by 
disease external to their canal. In affections of 
the mucous membrane, a morbid augmentation 
of the quantity of gas usually contained in the 
bowels is much more common than a diminution 
of it. In many cases, the intestines are extremely 
distended with gas throughout the greater part of 
their whole course ; and when this distension is 
of some continuance, it has been frequently 
described as a distinct disease, under the name of 
tympanites or tympany, from the drum-like 
tension of the abdomen produced by it, and the 
loud sound elicited on percussion. 

It is obvious that a practitioner, well acquainted 
with the various kinds and degrees of sound usu- 
ally elicited in health from the regions chiefly 
occupied by the hollow viscera, may derive mucb 



32 



ABDOMEN, (EXPLORATION OF THE) 



important information calculated to aid his diag- 
nosis and prognosis, and to regulate his practice, 
by attending to the modification of those sounds 
produced by disease. In relation to this point, 
it suffices to notice the different judgment that 
will lie formed in two cases having the same 
degree of swelling, but with the sound quite dull 
in the one, and tympanitic in the other. 

When the bladder of urine is at all distended 
by its natural contents, so as to project beyond 
the edge of the pubes, its presence may always 
be easily ascertained by percussion. It yields a 
dull sound, like that of ascites, which contrasts 
well with the clear intestinal sound on all sides 
of it, but is yet of a different character from that 
yielded by a solid tumour. M. Piorry assures us 
that it is even possible to ascertain the presence 
and dimensions of the gall-bladder by the same 
means. We have never attempted to verify this 
statement. 

The presence of the solid viscera and of solid 
growths of a morbid kind is ascertained chiefly 
by the contrast of their dull sound with the 
resonance of the intestines around. It is, there- 
fore, important to be well acquainted with the 
natural seat and limits of these viscera in the 
state of health. 

In judging of morbid states of the liver, suf- 
ficient allowance is not always made for varieties 
that occur in its position, independently of any 
disease in the organ itself. Disease of the right 
cavity of the chest will occasion retraction or 
depression of the liver, according as it is of a 
kind to elevate or depress the diaphragm. Dis- 
of the abdomen will have the same effect 
by a reverse operation. Alteration of the shape 
of the lower part of the chest from the effects of 
stays, sometimes occasions a remarkable change 
in the relative position of the liver as well as of 
the stomach. From this cause the liver is some- 
times completely hidden beneath the compressed 
border of the thorax 5 at other times its left lohe 
is thrust before the stomach into the left hypo- 
chondriac region, or depressed into the umbilical. 
Besides, the size of the liver varies considerably 
in different persons, and m the different periods 
of life. In the majority of healthy and well 
formed persons, its lower border scarcely descends 
below the margin of the ribs, or encroaches upon 
the scrobiculus cordis. The situation and size 
of the liver, both in health and disease, are well 
ascertained by percussion. It is bounded by the 
stomach on the left side, and the colon below, 
both generally containing air ; and it is accurately 
hounded above by the lungs, always, in health, 
full of air : it lies, therefore, yielding its dull 
sound, in the midst of a sonorous region. If the 
practitioner is well acquainted with the ordinary 
size of the healthy organ, and takes into account 
all the circumstances that can influence its posi- 
tion in the individual case before him, he will not 
often be mistaken respecting the actual size of the 
liver, nor have much difficulty in determining 
whether this size is to be considered morbid. 
Manual examination will here be of great value 
aa far as respects the inferior or abdominal border 
of the liver ; but percussion and auscultation can 
alone point out the upper limits of the viscus.* 

* It is impossible to notice every peculiarity of disease 
thai may interfere with the manifestation of the usual 
•ound? of health; or to lay down rules of diagnosis 



The situation of the spleen being a good deal 
dependent on that of the stomach, is less fixed 
than that of the liver ; still, generally speaking, 
it may be said to be placed in the left superior 
dorsal region immediately below the diaphragm, 
and a little to the left of the spinal column. It 
is entirely covered by the ribs. Being surround- 
ed on all sides, like the liver, by hollow viscera 
containing air, (except when it adjoins the kid- 
ney,) it would be very easily distinguishable by 
percussion, if it were placed as close to the 
exterior of the body as the liver is. But this is 
not the case ; and we cannot, therefore, expect 
either the same distinctness in our signs, or accu- 
racy in our diagnostics, here, as in percussion of 
the hepatic region. Still, there can be no doubt 
that when the spleen is enlarged so as to displace 
the floating viscera, and approach the side, its 
presence may be readily recognised. M. Piorry, 
indeed, says that its exact site may be ascertained, 

in most cases, even in health. 

• 

The kidneys are usually seated about the mid- 
dle of the inferior dorsal region, on a level with 
the last dorsal and two upper lumbar vertebra?. 
Being separated from the surface by the thick 
mass of the lumbar muscles, it is hardly to be 
expected that their place should be indicated by 
percussion ; and we confess that we never made 
the experiment. If this accuracy of diagnosis 
were attainable, we are somewhat doubtful if it 
would be of any use. Still M. Piorry assures us 
that, both in health and disease, percussion is 
capable of making known the position of the 
kidneys, when exercised with certain necessary 
precautions detailed by him. 

In no morbid condition of the abdominal cavity 
are the results of percussion more satisfactory 
than in the case of liquid effusions into the peri- 
toneum. In most cases, either inflammatory or 
simply dropsical, the effused fluids seek the low- 
est level, according to the position of the patient, 
leaving the hollow viscera, containing air, to float 
partially above them. Over the space occupied 
by the latter, percussion will, of course, elicit the 
tympanitic resonance ; while over that occupied 
by the denser liquid, the sound will be compara- 
tively dull or dead. In general, the demarcation 
of the sonorous and dull regions is very abrupt 
and distinct ; and is proved, by experiment, to 

applicable to every such peculiarity. While engaged in 
writing the preceding remarks, we met with an instance 
of this sort, in the case of a man affected with ascites 
and anasarca. In this case, the liver was evidently very 
small, at least in its interior portion, because percussion 
elicited the clear tympanitic sound over all tie- border of 
the ribs and for a couple of inches above this. It was 
also evident that there was no accumulation of water 
in the chest, at least to any extent ; and there existed 
no sign of pulmonary disease. On the lower part of the 
right side of the chest, above the usual site of the liver, 
there was, however, a space of three inches broad, in- 
cluding the nipple, ami stretching laterally to a consider- 
able extent, which yielded a perfectly duil sound. Was 
this the liver stretching so high into the thorax ? or was 
it a tumour attached to the diaphragm? Dissection ex- 
plained the difficulty at once. It appeared that this man 
on some former occasion had had inflammation of the 
peritoneal coat of the upper face of the liver, which had 
terminated in partially attaching the viscus to the dia- 
phragm in such a nay as to form, by the adhesion, a 
shut but empty sac between the peritoneal coats of the 
liver and diaphragm. On the supervention of the drop- 
sical disposition, this portion ot tin- Berous membrane 
threw out its serum like the rest; but having 110 outlet 
it accumulated; and finding the diaphragm more yield- 
ing than the liver, it thrust the former upwards into the 
chest in the form of a tumour. The sac contained ueai 
ly a pint of serum. 



ABORTION. 



33 



be always that of the temporary level of the fluid. 
Change of position immediately alters the rela- 
tive positions of the dull and tympanitic regions. 
For example : in the case of a moderate accumu- 
lation of fluid, when the patient is in the erect 
position, the whole of the lower parts of the 
abdomen, viz. : the hypogastric, inguinal, and 
part, at least, of the epigastric, iliac, and inferior 
dorsal regions, will yield the dull sound ; but if 
the patient assumes the horizontal posture, all the 
anterior regions will resume the tympanitic re- 
sonance, while the dulness will be transferred to 
the whole of the lateral and dorsal regions. The 
degree of dulness of sound is found to be in- 
creased in proportion as the percussion is made 
low down in the regions containing the fluid. It 
was formerly stated that, if in cases of moderate 
effusion we press the plate forcibly upon the 
abdomen, we frequently reach a point where per- 
cussion elicits a dull sound, although it had 
elicited a clear sound from the same spot when 
the plate was only pressed gently upon the sur- 
face. The fact is explained by the pleximeter 
having in the former case reached the level of the 
fluid in the abdominal cavity, after displacing or 
compressing the hollow bowels which had been 
floating above it. These various results indica- 
tive of the presence of fluid are* frequently obtain- 
ed when the quantity is so small as to be undis- 
coverable by fluctuation. As they are equally 
observed whether the effusion is the consequence 
of inflammation or simple dropsy, they will be 
found in most cases of peritonitis ; and, therefore, 
percussion will prove, not merely a diagnostic of 
this disease, but a valuable aid in discriminating 
it from enteritis, properly so called. In inflam- 
matory affections of the abdomen, it is necessary 
to be very gentle in our operations on account of 
the painful state of the parts ; and, in such cases, 
it may be further requisite to employ a broader 
plate, with the view of diffusing the pressure 
more equably over the tender parts.* 

In the encysted dropsy of the abdomen, the 
results of percussion are, in several respects, dif- 
ferent ; and the differences supply means for 
enabling us to distinguish the two affections. In 
the encysted dropsy the sound is much duller ; 
the fluid not being able to change its place, the 
sphere of dull sound is almost fixed ; or if (he 
whole cyst changes its place, which it sometimes 
does in different postures of the patient, the 
hydrostatic line of level is never formed as in the 
case of the loose effusion. In these cases, also, 
we frequently find the tympanitic resonance 
beneath the cyst, which could not be the case in 
simple ascites ; and the line of demarcation be- 
tween the dull and sonorous regions is seldom 
quite straight, as in the last-named disease. It 
is hardly necessary to caution the reader that, in 
all these cases, no one should be so imprudent as 

* M. Tarral has recently described a new mode of 
detecting abdominal effusions, which he terms superficial 
fluctuation, (fluctuation periphirique). His description 
of it is as follows : " Place both hands on the abdomen, 
two or three inches apart, ami with the two fore-fingers 
parallel to each other ; then, while the hands are still in 
this position, give slight blows or shocks on the abdomi- 
nal parietes with the fore-finger of the right-hand : this 

will pro, I an undulatnry motion in the effused fluid, 

which will h ■ readily perceived by the fore-Anger of the 
left-hand. The same result is obtained, if the right- 
hand is quit.' raised, provided the hlows are given ob- 
liquely, as if brushing the surface." — Piorry,du Procidi 
Operatoire, p. J:i7. 

Vol. I. — 5 



to trust to percussion alone in forming a diag- 
nosis. In all kinds of cysts, as well as in other 
tumours, developed among the floating viscera, 
palpation will be, at least, of equal value with 
percussion. There are, indeed, few cases, if any, 
in which the one should be employed exclusively 
of the other, in the investigation of abdominal 
diseases. In the case of solid tumours, as of 
cysts, when they approach the surface, and 
thereby displace the floating viscera, they yield 
the dull sound on percussion. When seated 
more profoundly, the dull sound is only obtained 
by depressing the abdominal parietes to the level 
of the solid mass. 

Percussion is sometimes productive of the best 
results in cases of indurations and tumours of the 
abdominal parietes, such as chronic abscess in the 
interstices of the muscles. In such cases it is 
sometimes difficult to decide, especially in fat 
persons, whether the tumour has its seat within 
the cavity ; and here we have found percussion 
afford great aid in removing the difficulty. When 
the tumour is seated in the parietes, percussion, 
when applied with sufficient force, will elicit the 
clear sound, however solid the tumour may be, if 
it is not of much greater size than is usually the 
case in such instances. In a solid tumour, spring- 
ing fiom within the abdomen itself, and pressing 
against the parietes, the sound will be perfectly 

dead. T ,-, 

John v orbes. 

ABORTION, (abortus,) signifies the expul- 
sion of the foetus from the uterus before its dif- 
ferent organs have been sufficiently developed to 
enable it to support an independent life. When 
the product of conception is expelled between 
this period and the full term of utero-gestalion, 
the process is usually termed premature labour. 

Abortion is a frequent occurrence in the early 
months of pregnancy, particularly among women 
of the lower classes of society, who are exposed 
to much bodily fatigue and mental anxiety. 
[Dr. Collins, of Dublin, met with 203 prema- 
ture cases in 16,414 ; and Dr. Beatty, with 21 
premature cases in 1200. Dr. Churchill records 
65 cases of abortion in 1705 deliveries; Madame 
Lachapelle, 116 cases in 21,960; and M. Deubel, 
35 in 420 ; making, in all, 530 premature cases in 
41,699 deliveries, or 1 in ?8j. It has been sug- 
gested by Dr. Guy as probable, that the small 
proportion observed by Madame Lachapelle is 
owing to the fact, that the females, who came 
under her observation at La Maternite, were 
in the latter months of pregnancy, when abor- 
tions are comparatively rare ; and the same ex- 
planation may apply to other cases.] It is most 
liable to occur in plethoric, irritable, and nervous 
subjects ; in women who are affected with con 
stitutional diseases, more especially syphilis ; ii. 
those who have deformity of the bones of the 
pelvis, or some organic disease in the uterine 
organs. All the chronic diseases, therefore, to 
which the uterus and its appendages are liable, 
may be considered causes of abortion. The pro 
duction of polypi in the cavity of the uterus, or 
of fibro-cartilaginous tumours in its walls, and 
morbid adhesions of the uterus to the surround 
ing viscera, may all, by impeding the regulai 
enlargement of the gravid uterus, give rise to 
premature expulsion of its contents. 

Other predisposing causes of abortion, though 



34 



ABORTION. 



less evident than those now enumerated, are also 
usually admitted by authors : for example, leu- 
corrhcea, irritability or too great contractility and 
rigidity of the uterine fibres and blood-vessels. 
Those who have insisted on rigidity of the uterine 
fibres as a cause of abortion have been led into 
error, by supposing that the uterus enlarges during 
pregnancy by the mere force of the mechanical 
distension of the ovum, and not by the gradual 
developement of all the textures of the organ, in 
exact correspondence with the growth of the 
organs of the foetus. 

But by far the most frequent cause of abortion 
is in the product of conception itself; viz. in a 
diseased condition of the foetus, or its involucra, 
by which it is deprived of life, and afterwards 
expelled from the uterus like a foreign body. The 
blighted ovum is thrown off from the parent, as 
fruit which has become withered is separated from 
the branch of the tree on which it has been pro- 
duced. We have examined numerous ova which 
have been prematurely expelled, and in many of 
these, where no disease was obvious at first, some 
morbid state of the membranes, placenta, or em- 
bryo itself, has been detected, sufficient to account 
for the accident, wholly independent of any con- 
stitutional or local affection of the mother. Some- 
times the chorion has been thickened, opaque, and 
extremely irregular, or lobulated, on its internal 
surface. The amnion, in some cases, has under- 
gone similar changes, so that the healthy appear- 
ance of the involucra has been entirely lost. A 
collection of serum, or blood, has not unfrequently, 
also, taken place, between the chorion and amnion. 
The placenta, in some cases of abortion after the 
third month, has been hard, like cartilage, small 
and imperfectly formed, with calcareous particles 
deposited in its substance : in others, the placenta 
has been unusually large, and its vascular struc- 
ture has been changed into a soft yellow fatty 
substance ; or hydatids have been developed in its 
tissue. The umbilical cord, in these instances, 
has been remarkably slender, and the foetus has 
appeared to perish for want of a proper supply of 
nourishment ; and not from any defect in the 
organization of its internal parts. 

The brain of the foetus, or the thoracic or ab- 
dominal viscera, may all undergo various altera- 
tions of structure incompatible with life ; and 
where the life of the foetus is extinct, it becomes 
an extraneous body ; expulsive efforts on the part 
of the uterus are usually soon set up, and abortion 
ensus as the necessary consequence. When the 
ovum is healthy, it adheres to the uterus with 
great force ; but when diseased, the slightest shock 
to the mother, the most trifling mental affliction, 
is sufficient to cause it to be expelled. Women 
have had the bones of the extremities fractured 
during pregnancy, and have suffered other grievous 
injuries, without miscarrying. A woman men- 
tioned by Mauriceau escaped by a window from 
the third floor of her house when on fire, and in 
her fall to the ground fractured her arm, yet 
abortion did not follow. The case of a young 
woman with a narrow pelvis is related by Madame 
Lachapelle, who threw herself into a deep pit, and 
suffered injuries of which she subsequently died, 
yet the foetus was not expelled. 

All cases of abortion cannot, however, be 
referred to organic diseases of the uterine organs, 
or of the embryo and its involucra ; since it can- 



not be doubted that the process often arises from 
accidental detachment of the placenta, in conse- 
quence of an unusual determination of blooa to 
th,- ^ essels of the uterus, or contraction ot its 
parietes. The placenta adheres to the uterus by 
means of the deciduous membrane alone, which 
is directly applied to the openings of the uterine 
sinuses. If the impetus of the blood in these be 
increased by an excited state of the general circu- 
lation, or by irritation of the uterus itself, an unu- 
sual afflux of blood to these vessels will take 
place, and the placenta will be forced from its 
connexion with the uterus, more or less exten- 
sively, by the extravasation of blood from the 
openings of the uterine sinuses, between the 
placenta and uterus. If this takes place to a con- 
siderable extent, the process of gestation will be 
arrested, and in a longer or shorter period the 
ovum will be expelled. In plethoric women, or 
in those who menstruate copiously, very slight 
causes may give rise to a hemorrhagic effort in the 
uterine vessels, and to the extravasation of blood 
between the uterus and placenta, with the other 
consequences now described. A plethoric state 
of the uterine organs is most frequently met with 
in those who lead luxurious lives, who sleep in 
warm soft beds, and indulge to excess in animal 
enjoyments. Thrs plethoric state of the uterus 
commonly gives rise to a sense of weight in the 
hypogastric region, or irregular pains of the uterus; 
but it sometimes happens that the blood suddenly 
bursts from the uterine vessels, and detaches the 
placenta, where there has existed no previous 
sign of unusual determination of blood to the 
parts. 

Besides these causes, there are others which 
excite undue determination of blood to the uterine 
organs, as violent exercise, dancing, the use of the 
warm bath, the employment of acrid cathartics 
and emetics, spontaneous diarrhoea, the irritation 
of hemorrhoids, injurious pressure of the hypogas- 
trium, and violent passions of the mind. Opening 
the membranes of the ovum and evacuating the 
liquor amnii certainly gives rise to premature 
expulsion of the contents of the gravid uterus. 

[Occasionally a habit of aborting is acquired ; 
so that it is extremely difficult for the female to 
pass the period at which the accident has occurred 
in previous pregnancies. Cases have occurred in 
which it has happened upwards of twenty times 
in succession, about the same period of gestation.] 

The symptoms which precede abortion will be 
greatly modified by the exciting cause. For the 
most part, the expulsive process is preceded by 
unusual depression of strength and spirits ; by 
attacks of faintness, sense of coldness in the pelvis, 
palpitation, flaccidity of the breasts, a disordered 
state of the stomach and bowels, and other symp- 
toms, which indicate that the embryo has been 
deprived of life. 

Where an unusual afflux of blood to the uterus 
is the cause, the uterine pains or contractions are 
usually preceded for some days by rigours, lassi- 
tude, heat of skin, thirst, loss of appetite, excited 
state of the circulation, and sense of weight in the 
pelvis and loins. A greater or smaller quantity 
of blood then escapes from the uterus and vagina 
with pains occurring at intervals, like the pains of 
natural labour. Where the discharge of blood ; s 
great, the placenta has usually been extensively 
detached from the uterus, and all efforts to prever 



ABORTION. 



35 



the establishment of contractions are consequently 
unavailing. In some cases, where a considerable 
hemorrhage has taken place, with irregular pains, 
in the early months, the hemorrhage and contrac- 
tions have both been suspended by the remedies 
employed, and the foetus has been retained until 
the full period. In no case, however, has the pro- 
gress towards the complete expulsion of the ovum 
been averted, where the pains have recurred at 
regular intervals, with discharge of blood from the 
uterus, or a certain quantity of a dark-coloured 
serous fluid, with softening of the os and cervix 
uteri, and the formation of the bag of waters in 
the mouth of the uterus during the pains, have 
taken place. Under such circumstances, all our 
efforts to prevent abortion will prove wholly inef- 
fectual. 

When the embryo is dead, it is often expelled 
in a short period, with little pain and trifling loss 
of blood ; in other cases the process is very pro- 
tracted, continuing many days ; and in some rare 
cases which have been reported, the ovum, after 
having been retained in the uterus many months, 
has passed through various stages of putrefaction 
or decomposition. The embryo may die before 
the end of the third month, and not be expelled 
till the fourth or fifth month ; or a foetus of seven 
or eight months may lose its vitality, and not be 
expelled till the full period of gestation is com- 
pleted. In twin cases one fectus may die in the 
latter months, and be retained until the full period, 
and then expelled with the living child. 

It has been supposed that the embryo may be 
expelled, and yet the membranes continue to 
adhere to the uterus, and be completely developed. 
The membrana decidua is said to acquire a con- 
siderable thickness, and the amnion entirely to 
disappear, while the cavity of the chorion gradu- 
ally contracting, the mass which remains is only 
a red fleshy substance, in the centre of which 
there is sometimes visible a small serous cavity. 
M. Velpeau and other French pathologists have 
explained the formation of fleshy moles on this 
principle, but their opinion is not supported by 
satisfactory proof; for though these substances 
are invariably the products of conception, it is not 
certain that they are formed by the growth of the 
membranes subsequent to the death and expulsion 
of the embryo. In several cases of this descrip- 
tion no embryo was at any time discharged. 

Treatment! — In premature expulsion of the 
ovum from organic disease of the uterine organs, 
or from alterations of structure in the embryo or 
its involucra, any plan of treatment is not only 
inefficacious, but even injurious, where the con- 
tractions of the uterus have been excited to throw 
off its morbid contents. Where the symptoms of 
abortion come on without any apparent cause, we 
have reason to fear that they arise from this state 
of the uterus or its contents. The treatment must 
be directed to the following points : first, to pro- 
cure a complete separation of the ovum ; secondly, 
to moderate the hemorrhage and pain which may 
accompany it. 

By removing plethora, where there is general 
fulness and excitement, by venesection, and by 
calming the violence of the uterine contractions 
by sedatives, we shall often prevent a protracted 
discharge of blood ; and by obtaining relaxation 
of the os and cervix uteri, favour the complete 
escape of the ovum. Where there are no signs 



of local or general plethora and excitement, blood- 
letting is contra-indicated. 

In threatened abortion from congestion of blood, 
or unusual determination pf this fluid to the ute- 
rus, with slight detachment of the placenta, and 
irregular uterine contractions, it is possible in 
some cases, by the prompt application of remedies, 
to arrest the mischief. The greatest mental tran- 
quillity, and absolute rest in the horizontal posture, 
on a mattress or couch, with the body lightly 
covered, should be enjoined in all cases of threat- 
ened abortion of this description. If the patient 
is plethoric, and the pulse accelerated, blood is 
immediately to be detracted, in quantity propor- 
tioned to the urgency of the symptoms Twelve 
or sixteen ounces should be taken from the arm, 
and, if necessary, the same quantity should again 
be taken after a time. Cold applications, and 
e,ven ice, if it can be procured, should be applied 
over the pubis. A dose of laudanum, or liquor 
opii sedativus, is to be given, or a starch and 
laudanum clyster may be administered, to prevent 
or quiet the uterine contractions. The acetate of 
lead is in these cases a valuable remedy. Two 
grains, combined with a quarter of a grain of 
opium, may be taken every three hours until the 
discharge of blood begins to abate. 

[Should the flooding be excessive, the tampon 
should be had recourse to. This may consist of 
a piece of soft sponge, of sufficient size, which 
may be introduced in the dry state, or, lubricated 
with oil or melted lard. It favours the formation 
of a coagulum, and the consequent arrest of the 
hemorrhage. When any portion of the ovum is 
retained in the uterus, it is recommended by Dr. 
Dewees to employ a wire crotchet, as 
represented in the marginal figure, which 
is one-third of the proper size. It con- 
sists of a piece of steel, of the thickness of 
a small quill at its handle, and gradually 
tapered off to its other extremity, which is 
bent to a hook of small size. When the 
placenta is felt to be embraced by the 
neck of the uterus, the crotchet may be used 
in the following manner. The fore-finger 
of the right hand is placed within, or at the 
edge of the os tines ; and with the left the 
hooked extremity is conducted along this 
finger, until it is within the uterus. It is 
gently carried up to the fundus, and then 
slowly drawn downwards, which causes 
the curved point to fix in the placenta. 
It may then be withdrawn, and the pla- 
centa with it. In every case in which 
Dr. Dewees used it, the discharge in- 
stantly ceased. 

Dr. Bond, of Philadelphia, has contrived 
a forceps, with the view of supplying the 
acknowledged defective means, in present 
use, for the removal of the placenta in 
cases of abortion attended with uterine 
hemorrhage. The forceps is about ten 
inches long, curved laterally upon «i 
radius of about twelve inches — the handles being 
four inches, and the blades about six inches in 
length, The blades terminate in an elliptical 
expansion, ibout an inch long, and three or four 
eighths of an inch wide, without any fenestra. 
The handles and blades, including the expandcu' 
part, are bevelled or rounded off, so as to avoid 
the risk of wounding or pinching anv of the soft 



36 



ABSCESS, (I 



parts. Within this rounded edge, the expanded 
part is made very rough, so as to maintain a 
secure hold upon the body embraced. The forceps 
may be made straight; but Dr. Bond thinks, that 
in most cases the curved instrument will be found 
more convenient for the operator and easier for 
the patient.] 

As to the subsequent effect of abortion, it 7nay 
be stated as a general fact, that, in a very large 
proportion of cases, it produces little or no inju- 
rious effect on the constitution of the mother. It 
is an accident of very frequent occurrence in all 
countries, and has often occurred without leaving 
any permanent injury. Where the process of 
expulsion has been protracted, and much blood 
has drained from the uterine vessels, a proportional 
injurious effect has been the consequence on the 
general health of the mother. 

From what has now been stated respecting the 
causes and treatment of abortion, little requires to 
be said as to the management of women who are 
habitually liable to this accident. We are in 
possession of no means which can either prevent 
or remove the numerous organic diseases of the 
uterine organs, and of the embryo and its involu- 
cra. Much, however, may be done to avert the 
danger where it arises from plethora and irritation 
of the uterus alone, by obviating general fulness, 
and taking off the suceptibility to premature con- 
traction of the uterine fibres, by rest, mild diet, and 
the occasional use of anodynes. Where there is 
much constitutional debility present, we must 
adopt all the means we possess for relieving the 
weakness, and more particularly the cold bath, 
and proper diet and exercise. Warm rooms and 
late hours are to be avoided. 

[Dr. Churchill, considers, that one of the most 
effective means for breaking in upon the habit is 
to give the uterus a long rest, by separating hus- 
band and wife for several months ; and Dr. Hus- 
ton places great stress on the use of opiate injec- 
tions daily, with continuance in the horizontal 
posture. By these means, a tolerance on the part 
of the uterus has been acquired, which has allow- 
ed the gestation to go on until the full period.] 

The practice of inducing abortion for criminal 
purposes has prevailed in all ages. In the early 
months it is extremely difficult, from the appear- 
ances in the mother, to ascertain with absolute 
certainty that abortion has taken place. In 
dysmenorrhea there are, sometimes, membranous 
substances thrown off from the inner surface of 
the uterus which strikingly resemble the products 
of conception ; and even if the uterine organs 
are examined, we shall not arrive at complete 
certainty on the subject. Blood-letting, acrid 
cathartics, diuretics and emmenagogues, cantha- 
rides, the juniperus sabina, and various local 
means, have been employed to excite premature 
expulsion of the embryo. By the Ellenborough 
Act, passed in 1803, it was ordained in this coun- 
try, " that if any person shall wilfully administer, 
or cause to be administered, any medicine, drug, 
or other substance or thing whatsoever, or use, or 
cause to be used or employed, any instrument, 
&c, with intent to procure the miscarriage of any 
woman not being, or not being proved to be, quick 
with child, at the time of committing such thing, 
or ising such means, then, and in every such 
case, the person so offending, their counselors, 
aiders, and abettors, shall be and are declared 



NTERNAL) 

~ilt v of felony, and shall be liable to be fined, 
^oned, set in and upon the pillory, publicly 

or privately whipped, or transported beyond the 
1' for any term not exceeding fourteen years 
The same act ordains that administering medi- 
cines, drugs, &c, with the intent to procure abor- 
tion, after quickening, shall be punishable with 

death. . , , . 

("The absurd distinction between quick and not 
quick with child, which is still adhered to in the 
laws of some of the States, has been abandoned 
m England, in a more recent statute— 1 Vic- 
toria, cap. 85. The following is the law as it 
now stands: "And be it enacted, that whoso- 
ever, with intent to procure the miscarriage of 
any 'woman, shall unlawfully administer to her, 
or cause to be taken by her, any poison or other 
noxious thing, or shall unlawfully use any in- 
strument, or other means whatsoever, with the 
like intent, shall be guilty of felony, and being 
convicted thereof, shall be liable, at the discretion 
of the court, to be transported beyond the seas 
for the term of his or her natural life, or for any 
term not less than 15 years, or to be imprisoned 
for any term not exceeding 3 years."] 

Robert Lee. 

ABSCESS, Internal The term abscess 

(derived from abscedo, to depart, denoting that 
parts which were in contact have become sepa- 
rated) implies, in its pathological sense, a collec- 
tion of pus in any of the tissues or organs of the 
body. The doctrines of suppuration will be fully 
discussed in the article Inflammation : in the 
present we shall consider the subject of internal 
abscess, including what are termed purulent form- 
ations. 
I. Of the yahiotjs modes in -which rrnc- 

LENT FORMATIONS TAKE PLACE. 

The theory of suppuration, or the process by 
which the secretion of pus from an inflamed sur- 
face takes place, is, that the purulent fluid is sepa- 
rated from the blood by a peculiar action of the 
vessels of the inflamed part, of the precise nature 
of which we are ignorant. 

When purulent matter is confined, and not 
infiltrated through the structure of an organ, it 
constitutes, in strict medical language, an abscess, 
the boundary of which is formed either by the 
tissue of the organ itself, or by what is called an 
accidental tissue. In both cases the formation of 
the boundary is accomplished by the same means, 
viz. : the effusion of coagulable lymph, which, in 
the former, produces the union and consolidation 
of the tissue of the organ in immediate contact 
with the pus, and thus prevents its diffusion ; in 
the latter, it forms a more or less perfect mem- 
brane over the whole of the surface from which 
the purulent secretion had taken place, and hence, 
the pus being enclosed, as if in a shut sac, is said 
to be encysted. It is to collections of purulent 
matter of the latter kind only, that the term 
encysted abscess is applied. 

It would appear that the cysts of abscesses 
have the property of secreting as well ;,s of ab- 
sorbing surfaces, from the circumstance of an 
encysted abscess being often speedily filled after 
the pus has been evacuated, and that abscesses do 
occasionally disappear without any external open- 
ing; the only inference in such cases being, that 
the pus has been absorbed. 

In most instances, the structure of the tissue 



ABSCESS, (INTERNAL) 



37 



surrounding a purulent collection exhibits evident 
marks of alteration. There is, in general, vas- 
cular turgesccncc ; sometimes softening; while, 
in the part occupied by the abscess, the proper 
substance of the organ has disappeared, its place 
being supplied by cellular tissue, in which the 
pus is deposited. 

Purulent collections are not always, however, 
bounded by adhesive inflammation or by a cyst, 
the pus as it is secreted being in many instances 
diffused through the tissue of the organ. Such 
infiltrations of pus happen more frequently in the 
lungs than in any other organ, and, till lately, 
were confounded with pulmonary abscess, which 
very Tarely occurs. In most instances the forma- 
tion of pus which constitutes these infiltrations is 
preceded by inflammation of the organ in which 
they are found, but in others it would appear, as 
we shall presently explain, that the matter is 
deposited by the blood in healthy structures. 

Another form of purulent collections is when 
pus is formed in natural cavities. Serous mem- 
branes not unfrequently assume a suppurative 
action as a consequence of inflammation, and in 
this way large accumulations of puriform fluid 
take place in the cavity of the thorax, in the abdo- 
men, and in the interior of the large joints. 

The fluid effused varies in colour and consis- 
tence according as it is the product of acute or 
chronic inflammation. If it is the result of acute 
inflammation, it is of a pale yellow or straw 
colour, transparent, or more frequently turbid, 
from admixture of small portions of coagulable 
lymph, giving the fluid very much the appearance 
of unstrained whey ; when it occurs after chronic 
inflammation, the fluid is not only more abundant, 
but also more turbid, from the greater quantity of 
purulent flakes with which it is mixed, and which 
are often deposited in such abundance as to give 
the effusion very much the appearance of common 
pus. These puriform fragments fall to the most 
depending part of the cavity, so that the upper 
portion of the fluid is of a thinner consistence 
than the under or more depending. The portions 
of the inflamed membrane are covered with an 
exudation of coagulable lymph, which, when 
recent, is easily detached ; and when this new 
formation has become vascular, it is changed into 
a new structure, to which the term false mem- 
brane has been given. 

We have hitherto been considering the forma- 
tion of pus as the consequence of previous in- 
flammation of the structure in which it is found. 
It is necessary, however, to point out, that pus is 
occasionally deposited in parts which exhibit no 
traces of the existence of antecedent inflamma- 
tion. This fact has been long known to patholo- 
gists. Mr. John Hunter was acquainted with the 
occurrence of these non-inflammatory purulent 
deposits, as appears from the chapter in his work 
on Inflammation, entitled, " Collections of Mat- 
ter without Inflammation," and since that time 
the fact has been noticed by various writers both 
in this and in other countries. 

Though Mr. Hunter states that there is often 
swelling, or thickening of parts, without the visi- 
ble or common symptoms of inflammation, and 
that there are collections of matter somewhat 
similar to suppuration which do not arise in con- 
sequence of common inflammation, he does not 
appear to favour the doctrine of the possibility of 



pus being absorbed into the blood, and afterwards 
deposited in another part of the body ; but to 
regard all such collections of matter as of a scro- 
fulous nature, and different from true suppuration. 
It is also evident that Mr. Hunter had only observ- 
ed these purulent depositions in external struc- 
tures. Subsequent observations however have 
proved that they also take place both in "internal 
organs and in the different cavities, though there 
be no evidence of inflammation having previously 
existed. 

It is the opinion of Andral and other patholo- 
gists that these purulent deposits are the results 
of absorption of pus, and that the pus, after it is 
absorbed from the suppurating cavity, is separated 
from the blood on the surface or in the interior of 
the various organs. Andral seems also inclined 
to think that pus is much more readily formed in 
some persons than in others ; in fact, that there 
is in some individuals what may be termed a 
purulent diathesis. 

These depositions of pus succeed most fre- 
quently to injuries and surgical operations. They 
are by no means however confined to these cases ; 
for instance, they are not uncommon after phle- 
bitis, or in fatal cases of puerperal peritonitis, and 
in inflammation of the uterus. They also occa- 
sionally, though rarely, occur after continued fever 
and erysipelas. 

There are few tissues in which these non-in- 
flammatory purulent deposits have not been found. 
They form in the brain, in the cavity of the 
thorax and abdomen, in the muscular tissue of 
the heart, in the parenchyma of the lungs, liver, 
and spleen, in the substance of the uterus, in the 
ovaria, in the external cellular membrane, and in 
the joints. 

II. Abscess in pahticclah tissuks. 

Although there is no structure in the human 
body, if the epidermis, nails, and hair be except- 
ed, which does not occasionally become inflamed, 
yet abscess does not form in every tissue ; a par- 
ticular kind of structure being apparently neces- 
sary to its formation. For instance, it cannot 
take place in the dense structure of fibrous or 
cartilaginous tissue, nor in that of serous mem- 
branes. When pus is discharged from these tis- 
sues, it is effused, either upon their surfaces, or 
into the cavities which they invest ; but abscess 
never forms in their proper substance. 

It would appear that abscess occurs in those 
organs only into which cellular membrane enters 
as one of their constituents : of all the structures 
of the body, cellular membrane is that in which 
abscess most frequently takes place. It forms 
more frequently in superficial than in deep-seated 
cellular tissue ; this depends not on the principle 
that there is a greater inherent disposition in 
superficial cellular membrane to assume inflam- 
matory action, but that from its position it is more 
likely to be exposed to the exciting causes of in- 
flammation than that which is deep-seated. 

Pus occasionally forms in muscular structure ; 
in those cases it is deposited in the intermuscular 
cellular tissue, the muscular fibre itself being 
apparently incapable of assuming the suppura. 
tive action. 

Purulent matter has been found in all tno 
parenchymatous tissues, either in the form of 
abscess or of purulent infiltration ; as, for ip 
stance, in the lungs, in the liver, in the spleeu 



38 



ABSCESS, ( 



pancreas, and in the kidneys. The encysted 
abscess is more common in the liver; the puru- 
lent infiltration in the other organs. 

With regard to abscess in nervous tissue, 
Andral remarks, "It is a question which yet re- 
mains to be decided, whether, when the nervous 
tissue is, in a state of suppuration, the pus is 
furnished by the nervous tissue itself, or by the 
cellular membrane which enters into its composi- 
tion. It is, however, certain, that in some cases 
of abscess of the brain we find in the seat of 
suppuration nothing but a congeries of cellular 
tissue, which, in all probability, is the only source 
from whence the pus is derived, inasmuch as the 
nervous tissue has completely disappeared. Cer- 
tain white softenings of the brain have been re- 
garded by some authors as the effect of a purulent 
infiltration of the nervous tissue. This is a mere 
gratuitous hypothesis; there is no proof whatever 
of the presence of pus in these cases of soften- 
ing : all that the most minute examination can 
detect is a diminution in the consistence of the 
nervous tissue, which in those cases appears to 
manifest a disposition to return to its original 
state." (Vol. i. p. 498, Translation.) 

In alluding to purulent effusions in the cavities 
which are lined with serous membranes, we stated 
that pus is frequently secreted by serous tissue in 
a state of inflammation. 

Mucous membranes, however, take on the sup- 
purative action more easily than the serous. 
From the extent of this structure in the animal 
economy, suppurative inflammation of mucous 
membranes is by no means uncommon. It 
occurs, for instance, in the bronchial membrane ; 
in the mucous lining of the kidney, bladder, 
and urethra ; in those shut cavities which are lined 
with mucous membrane, as in the maxillary and 
frontal sinuses; in the cavity of the tympanum, 
and in the ^ethmoidal cells. There is an import- 
ant difference in the inflammation of serous and 
mucous membranes — the former are very liable to 
adhesive inflammation, which it is hardly possible 
to excite in mucous membranes. 

Lastly, pus has been found in the vascular sys- 
tem, even in the blood itself. It has been detect- 
ed in the veins which return the blood from parts 
in which pus has been collected ; and also in in- 
flamed veins from puncture or after operations. 

The lymphatic vessels frequently contain pus, 
as, for instance, when they originate in textures 
which are in a state of suppuration. 

III. Or purulent Formation in Organs. 

1. Abscess in the Brain* — The brain is not 
unfrequently the seat of purulent deposits — the 
pus being, in some cases, infiltrated through its 
substance ; in others, collected in distinct cavities 
of different sizes. Sometimes several small ab- 
scesses unite so as to form a large cavity. 

Accoiding to Andral, in the primary stage of 
■erebral abscess, small drops of pus are seen scat- 
tered, in greater or less numbers, through a por- 
tion of the nervous substance, which is, at the 
same time, generally injected and softened. These 
drops gradually multiply, extend, and run into one 
another ; the solid parts between them grow softer 
and softer, and at last appear dissolved, as it were, 
in the pus, leaving only a few filamentous frag- 
ments behind. We have, then, a cavity, which 
however does not become distinctly circumscribed 
til' some time afterwards. When the parietes of 



INTERNAL) 

Vis cavity first become distinctly marked they 
consist merely of the nervous substance itself, 
bat, subsequently, we observe on their ■"»*» 
succession, first, a cellule-vascular substance, 
either spread uniformly over their whole extent, 
or existing only in small isolated points : secondly 
a ,-eal membrane, which, however, is still soft, 
flocculent, and separable from this nervous sub- 
stance : thirdly, a membrane of more firm con- 
sistence and distinct organization, which is suffi- 
ciently tenacious to be detached, either in shreds, 
or in a single piece, from the subjacent tissut 
(Vol. ii. p. 770.) 

The portion of the brain surrounding the ab- 
scess is generally softened, when it is recent ; but 
when it has existed for some time, the structure 
in the immediate vicinity is very liable to become 
inflamed, and to undergo various morbid altera- 
tions consequent to inflammatory action. 

When the abscess is situated near the ventri- 
cles, the purulent matter may force its way into 
them, from the slow and progressive destruction 
of the cerebral substance. When it is nearer the 
surface, it generally extends outwards, and then 
bursts between the membranes. 

In those cases in which the cerebral abscess is 
situated near the internal ear, the diseased action 
sometimes extends to the bony structure of this 
organ, destroying, first, the dura mater, and after- 
wards the petrous portion of the temporal bone. 
In this way the contents of an abscess in the brain 
have been discharged through the ear. In other 
instances the disease commences in the ear, and 
spreads to the membranes and substance of the 
brain. On dissection of such cases pus is found 
in the internal car ; the dura mater is softened 
and detached from the inner table of the skull ; 
the brain softened, and either infiltrated with pus, 
or containing an abscess. Several interesting cases 
of this kind are recorded in the works of Lalle- 
mand, Itard, Abercrombie, and others, to which 
the reader is referred. 

Cerebral abscess has been known in some in- 
stances to terminate, also, in destruction of the 
cribriform plate of the ethmoidal bone ; and in 
this way the matter has been discharged through 
the nasal fossa?. 

Purulent collections are occasionally found in 
the cerebellum. It has been remarked as diagnos- 
tic of these latter cases, that the mental powers 
are little, if at all, impaired; hence the symptoms 
of this lesion are very obscure and unsatisfactory. 
Andral states that in one solitary instance the tu- 
bercula quadrigemina and pineal gland were found 
completely destroyed, and their place occupied by 
an abscess. 

From the structure of the medulla spinalis be- 
ing precisely similar to that of the brain, this por- 
tion of the cerebral organization is liable to the 
same morbid changes. It has been found, in some 
instances, infiltrated with pus ; but there is no 
recorded case of abscess in its substance. Dr. 
Carswell met with a case of abscess of the spinal 
marrow, in a woman of 45 years of age, a patient 
of Mons. Louis, and the particulars of which were 
furnished him by Mons. Reynaud. The pus oc- 
cupied the cortical substance of the ri^ht anterior 
half of the spinal marrow, formed a clmdrotf 
abscess nearly live inches in length, and in son* 
parts, more than a line in diameter. A simi'ar 
collection existed in the left anterior half and was 



ABSCESS, (INTERNAL) 



39 



likewise limited to the situation of the cortical 
substance ; but it was not more than an inch in 
length, and terminated in the former, about an 
inch and a half above the primary seat of the in- 
flammation. 

With regard to the progress of cases of cerebral 
abscess, it would appear, from the symptoms ex- 
hibited previous to the deposition of pus, that in- 
flammation of the membranes or substance of the 
brain always precedes the formation of matter ; 
that after the deposition of pus the inflammatory 
action ceases, the symptoms diminish, and the 
functions of the brain are in part or entirely re- 
stored, notwithstanding the presence of such a 
foreign body as an abscess. The disease may then 
lie dormant for a considerable time, till the portion 
of the brain immediately in contact with the ab- 
scess takes on inflammatory action, and then the 
features of the malady again indicate inflamma- 
tion of the brain, of a more or less acute charac- 
ter, which generally proves fatal ; death being 
caused, not by the abscess, but by the inflamma- 
tion which supervenes. It must be admitted that, 
in investigating the history of several recorded 
cases of abscess of the brain, we find the train of 
symptoms very obscure and unsatisfactory. 

2. Ahscess in the interior of the Month 
and Pharynx. — The tongue is liable to inflam- 
mation and its consequences. Abscess in its sub- 
stance, however, is a very rare occurrence. Though 
indral alludes to it after acute inflammation, we 
have not been able to find an instance on record. 

Abscess frequently succeeds to inflammation of 
the tonsils and pharynx. The cellular tissue 
which surrounds the amygdalae is very liable to 
inflammation, which occasionally terminates in 
suppuration, the matter being discharged into the 
mouth. When the abscess is large, there is great 
danger of suffocation from the pressure of the 
swelling on the glottis. Such abscesses some- 
times form in the progress of acute diseases, more 
particularly fever, and the acute eruptive disorders 
of children, and give rise to all the symptoms of 
croup. If the tumour can be discovered, it should 
be opened by puncture ; indeed, in some instances 
of this kind, promptitude is necessary to save the 
patient's life. 

When an abscess occurs in the pharynx, it is 
apt to be overlooked, because, from its situation, 
it cannot be easily seen. When it is suspected, 
the finger should be carried down the pharynx, 
and, if necessary, the tumour opened, as death 
has occasionally occurred from its pressure on the 
glottis. This has occasionally happened in fever 
and acute eruptive diseases. 

Abscess in the cellular tissue connecting the 
mucous membrane with the muscular tissue of the 
oesophagus occasionally takes place, and gives rise 
to dysphagia, more or less urgent according to the 
extent of the purulent formation. When such 
abscesses attain a large size, they not only impede 
deglutition, but, by pressing on the trachea or 
lungs, produce considerable cough and difficulty 
of breathing. 

It is often very difficult to distinguish abscess 
from stricture of the oesophagus. In some in- 
stances, on the introduction of the probang, in 
order to ascertain the cause of dysphagia, the true 
nature of the disease has been ascertained by the 
rupture of an abscess, and the discharge of pus 
from the oesophagus. 



Adhesive inflammation sometimes takes place 
between abscess of the oesophagus and the adjoin- 
ing structures. In this way an abscess of the 
oesophagus, by adhering to the lung, has been dis- 
charged through the bronchial tubes. 

3. Purulent Formations in the Chest. — 
1. Purulent effusion into the cavity of the chest 
is not unfrequently the termination of pleurisy, 
particularly of the chronic form, and constitutes 
the disease termed empyema, which it is evident 
can only be considered as a secondary affection. 

The character of the fluid effused into the sac 
of the pleura differs according as it arises from 
acute or chronic pleurisy. When it succeeds to 
the former, it is of a pale yellow or straw colour, 
and generally a little turbid from being mixed with 
the coagulable lymph which is secreted by the in- 
flamed pleura. In chronic pleurisy, the fluid is 
not only in larger quantity, but of a consistence-. 
approaching to that of common pus, and generally 
mixed with masses of coagulable lymph. 

As pleurisy seldom takes place in both sides of 
the chest at the same time, effusion is generally 
observed in one cavity only. The fluid is some- 
times very rapidly secreted ; in other instances it 
takes place slowly and insidiously, the lung on the 
diseased side being compressed and pushed to- 
wards the upper part of the chest, in which situa- 
tion it is often retained by adhesions. The lung 
is sometimes so reduced in size as to be scarcely 
more than four to six lines thick, even in its mid- 
dle, and without careful examination might be 
considered to be totally destroyed. 

Sometimes a tubercle in the stage of softening, 
when situated near the pleural lining of the lung, 
bursts into the cavity of the chest. Pneu mo-tho- 
rax immediately follows ; this is succeeded by in- 
flammation of the pleura, and rapid effusion, 
which proves fatal in a very short time. In some 
cases, however, adhesive inflammation takes place 
between the pleura pulmonalis covering the tuber- 
cle and the walls of the thorax ; and thus the con- 
tents of the tubercular cavity are prevented from 
escaping into the sac of the pleura. In other in- 
stances, the adhesive inflammation extends to the 
parietes of the thorax, and in this way tubercular 
matter escapes through a perforation in the chest. 
(S'ee PxEtiMo-THORAX and Tubehcle.) 

Abscess of the liver or spleen occasionally bursts 
into the cavity of the pleura, and induces inflam- 
mation of the pleura and purulent effusion. 

2. Abscess of the lung is a lesion very rarely- 
met with, though from the frequent mention made 
of this pathological phenomenon by British as 
well as by some continental writers, we should be 
led to imagine it was a common termination of 
pulmonary inflammation. The opinion of Laen- 
nec on this point is very strongly expressed. It 
appears from his statement, that there is no organic 
lesion more rare than a collection of pus in the 
substance of the lung ; and that, among several 
hundred dissections of persons who died of peri- 
pneumony, he had only met with a collection of 
pus in five or six instances, and in these purulent 
deposits were neither extensive nor numerous in 
the same lung. In three cases only was the col- 
lection of pus of considerable extent, but in these 
there was no circumscribed cyst, the wall being 
formed by the pulmonary tissue, which was much 
softened and disorganized. Laennec also states 
that he had been able to find only two similar 



i[ 



ABSCESS, (INTERNAL) 



cases on record, neither of which had the proper 
cyst of phlegmonous abscess. 

Andral mentions the case of a new-born infant, 
whose lung contained several large abscesses. 
They bad no resemblance whatever to tubercular 
excavation. (Vol. ii. p. 539, Translation.) 

8. The kind of suppuration to which the sub- 
stance of the lung is occasionally liable is purulent 
infiltration. When it occurs, it is accompanied 
with hepatization, and appears to succeed to the 
most intense degree of inflammation. The con- 
sistence of the lung is at the same time much 
diminished, being so soft as to break down when 
handled. The pus appears in small detached 
points, so that when the lung is incised or 
squeezed, opaque yellow matter flows out. It may 
occupy an entire lobe, or only a small portion of 
it. and sometimes succeeds to pneumonia with 
great rapidity. Andral asserts that it has been 
found fully formed four days after the first symp- 
toms of pneumonia had made their appearance. 

The pulmonary parenchyma when infiltrated 
with pus presents a greyish ash colour, and, as the 
second stage of pneumonia has received the name 
of red hepatization, the former condition has been 
distinguished by the term grey hepatization. 
When the lung, in this state, is pressed, the puru- 
lent fluid exudes in greater or less quantity, and 
when it is squeezed out, the lung frequently re- 
assumes the red colour and hepatized appearance 
of the second stage ; thus proving, as Andral 
states, that the grey hepatization differs only from 
the red in having its structure infiltrated with pus. 

4. The process of softening of tubercles presents 
another variety of purulent formation in the sub- 
stance of the lung. These bodies, which vary in 
size, are in their first stage semi-transparent, and 
of a greyish colour ; in some cases almost colour- 
less and transparent. In this state they are pro- 
ductive of little inconvenience ; and hence indi- 
viduals, with pulmonary tubercles, often enjoy 
uninterrupted health for years. Sometimes a 
single tubercle has been found, but more generally 
they are numerous, and situated in the upper part 
of the lung. In some cases they are superficial, 
in others deep-seated. The tendency of these 
bodies is to soften, and to form a cavity in the 
portion of the lung where they are situated. The 
softening generally commences in the centre, and 
gradually increases towards the circumference, 
until the whole tubercle is converted into a fluid 
mass. One or more of the bronchial tubes become 
perforated, through which the tubercular matter is 
evacuated. A tubercular cavity is thus left, the 
interior of which is traversed by bands of pulmo- 
nary tissue, covered by tubercular matter, and the 
smaller branches of blood-vessels, which are gene- 
rally obliterated and transformed into impermeable 
cords. In some instances, however, these vessels 
continue open, and, by their erosion or rupture, 
occasion haemoptysis. The larger blood-vessels 
are pressed towards the side of the excavation, 
lining, as it were, its internal surface. The bron- 
chial ramifications undergo similar pressure ; but, 
according to Laennec, they appear to be rather 
enveloped than pressed aside by the tubercular 
matter, the pressure apparently soon obliterating 
their canal, as they are scarcely ever to be detected 
in the morbid structure of the lung. He moreover 
thinks they must have originally traversed the 
portion of lung occupied by the tubercles, as, in 



even the smallest excavation, one or more bron- 
chial tubes are found opening into it. These 
tubes appear not to open sideways, but are cut 
directly across on a line with the internal surface 
of the excavation, while from their direction, it is 
evident that they originally crossed the excava- 
tion. The boundary of these tubercular cavities 
is formed by the parenchymatous tissue of the 
lung, which has become more or less indurated or 
infiltrated with tubercular matter. The internal 
surface is lined by a false membrane, which is 
composed of concrete pus, and is so soft as to be 
easily detached by the scalpel. 

These cavities vary in number and size ; some- 
times there is only one cavity, in others there are 
several, which either remain isolated, or commu- 
nicate together by fistulous openings, varying in 
extent from such as will scarcely contain a filbert, 
to those which occupy a considerable portion of 
one lung. 

With regard to the possibility of the cicatriza- 
tion, or healing of tubercular excavations, it would 
appear, from the minute and distinct researches 
of Laennec, that this process does take place, 
though in a very small proportion of cases. For 
a minute account of the stages of this reparative 
process, we beg to refer to the work of Laennec, 
and to the article Tubercle. 

5. Besides the sero-purulent effusion into the 
pericardium (from pericarditis,') abscess has been 
found in the muscular structure of the heart itself. 
The abscess is not encysted, the pus being dif- 
fused in the cellular tissue, connecting its muscu- 
lar fibres ; and in all the instances recorded, it 
appears that the previous inflammation had been 
confined to the portion of the structure of this 
organ in which the abscess occurred. The sub- 
stance around the abscess is stated, in some cases, 
to have been natural ; in others, it appeared red 
and softened. 

Abscess of the heart, however, is a lesion very 
rarely met with, although frequent allusion to such 
cases is made by the older writers, who, no doubt, 
mistook the sero-purulent effusion into the peri- 
cardium for abscess. There are, however, on 
record several well-authenticated instances of true 
cardiac abscess. 

Laennec mentions the case of a man, sixty 
years of age, in whom he found an albuminous 
exudation of the consistence of boiled white of 
egg, and of the colour of pus, deposited among the 
muscular fibres of the left ventricle. The symp- 
toms before death (orthopnoea and indescribable 
anguish) indicated acute inflammation of some of 
the thoracic viscera. He alludes to another case, 
in a child twelve years of age, in whom he found 
an abscess of the size of a filbert in the left ven- 
tricle. This case was complicated with pericar- 
ditis. A similar instance is mentioned by Andral; 
(vol. ii. p. 345.) 

In a fatal case of phlebitis after venesection, 
which occurred at Bethlehem Hospital, Mr. Law- 
rence found, in addition to the disease of the bra- 
chial veins, pericarditis, with deposition of pus in 
the muscular substance of the left ventricle, which 
was also softened and partially broken down 
(Med. Chir. Trans., vol. xv., p. 124.) 

4. Purulent Formations in tlie Abdomen. 
— 1. In treating of the different modes in which 
purulent matter is deposited in natural cavities, 
we alluded to the suppurative inflammation of 



ABSCESS, (INTERNAL) 



41 



serous membranes. We have already observed 
that the secretion of puriform fluid is not an infre- 
quent termination of chronic pleurisy. The same 
thing happens in peritonitis, in fatal cases of which 
more or less sero-purulent effusion is found in the 
abdominal cavity. The consistence and quality 
of this fluid vary according to the duration of the 
disease ; and hence, from the character of the 
effusion alone, its duration may, in most instances, 
be inferred. In some instances, circumscribed 
cavities, containing puriform fluid, are found. 
These originate in cases of partial or circumscribed 
peritonitis, the boundary of the cavity being formed 
by the effusion of coagulable lymph, by which the. 
convolutions of the intestines become agglutinated. 
In other cases, purulent effusion into the abdo- 
men has been the consequence of the bursting of 
an abscess in some of the abdominal viscera — 
the liver, for instance — or of intestinal perforation. 
These intestinal perforations may occur in any 
portion of the alimentary canal, but most fre- 
quently take place in the small intestines, and are 
generally the consequence of follicular ulceration 
and progressive destruction of the muscular and 
peritoneal tunics. When the peritoneal coat gives 
way, the intestinal contents escape into the cavity 
of the belly, and rapid inflammation, followed by 
death, is the almost invariable result. 

In some cases, the adhesion of the bowel to 
some adjacent part has prevented the intestinal 
perforation. In a remarkable case of this kind, 
the abscess communicated with the caput coli, to 
which, and to the parietes of the abdomen, the 
omentum had contracted a very firm adhesion. In 
this manner a circumscribed cavity was formed, 
bounded by this portion of omentum, the posterior 
surface of the caput coli, and the portion of peri- 
toneum lining the parietes at the part. This cavity 
contained a small quantity of ill-conditioned pus, 
and three or four bodies which appeared to be the 
seeds of fruit covered by earthy incrustation. It 
communicated with the caput coli by a small 
irregular opening, the mucous membrane around 
which was thickened and vascular. (Abercrombie, 
p. 338.) 

2. Abscess of the liver is not very common in 
temperate countries, but is a very frequent termi- 
nation of hepatitis in warm climates. The pus 
may be either infiltrated through the substance of 
the liver, or may be contained in a cyst, forming 
the encysted hepatic abscess. 

Abscesses of this organ vary in extent, being 
sometimes very small, in other cases of a large 
size, not less than three to four pounds of purulent 
matter having been found in a single abscess. 
(Abercrombie.) They differ, also, in number : 
there may be one abscess only, or there may be 
several, which are either perfectly distinct from 
each other, or communicate by fistulous openings. 
Hepatic abscess, when of small extent, may be 
absorbed ; more generally, however, adhesive in- 
flammation takes place between the walls of the 
abscess and some of the surrounding structures. 
In this way the pus may be evacuated externally 
through the parietes of the abdomen ; into the 
right pleural cavity ; through the diaphragm ; or, 
should adhesion have taken place between the 
liver, diaphragm, and parenchyma of the lungs, 
the contents of the abscess may be coughed up 
through an opening in the bronchi, and the patient 
may eventually recover. In other instances, the 
Vox. I —6 »* 



abscess forms adhesion to some contiguous portion 
of the alimentary canal, into which the pus is 
evacuated and discharged, either by vomiting, 
should the abscess adhere to the stomach, or by 
stool, if the adhesion takes place to the alimentary 
canal. In a case related by Malpighi, in which 
the abscess was situated near the gall-bladder, 
adhesion took place, and the contents were dis- 
charged through the biliary duct into the bowels. 
Andral alludes to a case in which an abscess of 
the liver communicated with the interior of the 
vena cava, and to another in which it opened into 
the pericardium. (Vol. ii. p. 598.) 

3. The termination of inflammation of the 
spleen in abscess is uncommon ; indeed, idiopathic 
inflammation of this organ is a very rare disease. 
Purulent infiltration in the spleen, however, often 
takes place at the same time that pus is deposited 
in other parenchymatous structures. In these 
cases, it is probable that the pus is formed else- 
where, and only deposited in the spleen through 
the medium of the circulation. 

Andral mentions the case of a woman, in whom, 
on dissection, he found a number of small abscesses 
in the spleen, lungs, liver, and brain ; the uterus, 
however, was the organ in which the pus was 
originally formed ; for the symptoms of inflamma- 
tion of the uterus were those which appeared first; 
and in the instance of this organ there were 
several collections of purulent matter, while all 
the uterine veins were filled with pus. 

The pus, in abscess of the spleen, may be dif- 
fused through the parenchyma of the organ, or it 
may be confined in a cyst of variable extent. The 
structure surrounding the abscess is sometimes 
unchanged ; more generally, however, it is softened 
and considerably altered in its texture, so as to be 
pulpy and easily broken down. These abscesses 
often attain an extraordinary size. In a case 
recorded in the Memoirs of the Academy of 
Sciences, an abscess of the spleen contained thirty 
pounds of purulent matter. In another mention- 
ed in the same work, eight pounds of matter were 
drawn off by tapping. The patient died next day, 
and the spleen was found still to contain seven 
pounds of pus, the sac of the abscess being eigh 
teen inches in length and twelve in diameter. 

Like abscesses of the liver, those of the spleen, 
by forming adhesion to some adjoining viscus, 
may burst into the cavity of the pleura, {Tweedie, 
Clinical Illustrations of Fever,) stomach, (Coze, 
Journ. de Med. torn. 82,) colon, {Jacquinelle, 
Journ. de Med. torn. 88) ; or, by the cyst of the 
abscess forming adhesion to the kidney, the pus 
may be discharged with the urine. The matter 
may be, also, extravasated into the cavity of the 
belly, in which case it proves rapidly fatal ; or 
the abscess may form an external tumour in the 
left hypochondrium, and in this way the matter 
may be discharged externally, by an opening in 
the abdominal parietes. 

Among the lesions observed in the spleen m 
fatal cases of fever, abscess may be enumerated. 
Though rather uncommon, cases of this kind 
have been recorded. Mr. Wardrop states, in a 
note to Baillie's Morbid Anatomy, that in some 
of the British soldiers who suffered from the Wal- 
cheren fever, and who afterwards died in this 
country, the whole substance of the spleen was 
converted into a puriform fluid, contained in '.is 
proper capsule. 



42 



A B S T I N E N C E . 



4. The pancreas is very rarely diseased, altera- 
tions of structure being less frequently observed 
in this than in any other organ of the body. Sev- 
eral cases of pancreatic abscess, however, have 
been recorded. Baillie mentions one case of it : 
the abscess contained a considerable quantity of 
thin pus ; the pancreas being much enlarged in 
size. Portal mentions having met with several 
instances ; and Andral once found two abscesses 
imbedded in the structure of the pancreas, each 
of which might have held a hazel nut. In a case 
mentioned by Dr. Percival, in which there was 
jaundice with bilious vomiting, epigastric tumour 
with discharges of blood and fetid pus by stool, 
the pancreas was found greatly enlarged, and con- 
tained a large abscess, the ductus communis being 
obliterated by pressure. 

5. The intestinal absorbents occasionally sup- 
purate, the pus being either collected in a cyst, 
(the parenchyma of the gland being destroyed,) 
or diffused through their structure. In scrofulous 
children, in whom mesenteric disease is more fre- 
quently met with than in adults, these glands are 
enlarged, and when cut into are found to contain 
soft curdy matter intermixed with pus. 

6. Abscess is a common termination of inflam- 
mation of the kidney. Renal abscesses are gene- 
rally small ; they are sometimes, however, of con- 
siderable size, and lined with a soft membranous 
layer. Purulent infiltration oi the kidney has 
also been observed, co-existing with purulent col- 
lections in other organs. The abscess, again, may 
be exterior to the kidney, in the cellular tissue in 
which this organ is imbedded. The pus formed 
in renal abscess in general passes through the ure- 
ters into the bladder, and is then expelled with 
the urine. Adhesive inflammation may, however, 
take place between the wall of the abscess and 
the parietes of the abdomen, and a communication 
has thus been formed between nephritic abscess 
and the loins. In some rare instances the abscess 
has burst into the colon, and the contents have 
been discharged by stool. A case of this kind is 
mentioned by Lassus. 

It should be remembered, however, that when 
puriform matter is passed with the urine, it is not 
always from abscess of the kidney. The mucous 
membrane lining the pelvis and ureters, or the 
bladder, occasionally becomes inflamed, and after- 
wards assumes, like other mucous membranes, a 
suppurative action. It is impossible during life to 
distinguish the one class of cases from the other ; 
nor is this of much practical importance, since the 
treatment is precisely the same in both. 

7. Aoscess occasionally forms in the muscular 
structure of the uterus, either in a circumscribed 
cyst, or infiltrated through its substance. In these 
cases, the uterine and hypogastric veins often con- 
tain pus, and it is by no means uncommon, as 
has been already stated, to find purulent deposits, 
at the same time, in other organs. When pus is 
found in the uterine veins, the prevailing opinion 
among pathologists is, that it is the result of ute- 
rine phlebitis, and that the pus which is found in 
other organs is deposited by the blood in its pass- 
age from the uterus through the various parts of 
the system. Pus may also be collected in the 
cavity of the uterus and Fallopian tubes. Dr. 
Carswell met with one case in which the pus col- 
lected in the cavity of the uterus was prevented 
Vom escaping by the presence of a false mem- 



brane, which passed across the orifice of the neck 
of the uterus. 

8. Though abscess be an occasional termina- 
tion' of ovarial inflammation, it is by no mean* 
common. There are several examples, however, 
on record, of ovarial abscess which varied much 
in size. In a case which lately occurred to the 
writer of this article, (the prominent symptoms 
of which were uncontrollable vomiting and sym- 
pathetic fever,) the ovarial abscess was of the size 
of an orange. They sometimes attain an enor- 
mous size ; as in a case related in the North Ame- 
rican Medical and Surgical Journal for 1826. A 
woman had an abdominal tumour which was ima- 
gined to be ovarial dropsy. Its real nature was 
only discovered after death, when the tumour was 
found to be a sac, containing twenty pints of well- 
formed pus. 

In some cases, the capsule of ovarial abscess 
has burst, and the pus has been extravasated into 
the cavity of the belly. An interesting case of 
this kind is related by Dr. Seymour, in his work 
on Diseases of the Ovaria. In this cise, the 
young woman, after suffering some tijie from 
hectic fever, (the cause of which was not very 
apparent,) suddenly complained of most acute 
pain over the abdomen, and in a few hours expired. 
On opening the body, the cause of death was ap- 
parent. A large quantity of pus was effused into 
the peritoneal cavity, which had escaped from an 
abscess in the right ovary. 

The ovarial abscess sometimes adheres to an 
adjacent organ, either to the uterus, vagina, blad- 
der, or to some portion of intestine. In these 
cases, the pus is discharged eventually into the 
viscus to which the abscess adheres. 

Lassus mentions the case of a woman who had 
long suffered from pain in the right lumbar region, 
supposed to proceed from suppuration of the kid- 
ney, because pus was voided with the urine. Af- 
ter death, the right kidney was found in its natu- 
ral state, but there was an abscess in the right ova- 
rium, which was adherent to the bladder, into 
which the pus had passed through an ulcerated 
communication. Andral met with a similar com- 
munication between one of the ovaries and the 
bladder in a young woman, who died thirty -seven 
days after her confinement. . m 

A. TWEEDIE. 

ABSTINENCE. By this term is meant the 
excessive or total privation of food. 

The animal frame is described by M. Cuvier as 
a tourbillon, by which substances are continually 
taken from without, carried into the circulation, 
deposited, re-absorbed, ami finally rejected. The 
mass both of the fluids and of the solids is thus 
supplied, repaired, or renewed. If our object be 
to diminish this mass, abstinence affords us, not 
the most prompt, but the most permanent and 
natural remedy. 

Not the mass only, but the sentient and moving 
powers of the system arc diminished by the pri- 
vation of food ; and this both in regard to ani- 
mal and organic life, to use the useful and expres- 
sive terms of Bichat : so that if our further object 
be to reduce the powers of the system, abstinence 
still furnishes us with the most simple and direct 
remedy. 

The ancient physicians were so impressed with 
the importance of various modifications of diet in 
the treatment of diseases, that they divided the 



ABSTINENCE. 



43 



whole art of physic into dietetics, pharmaceutics, 
and surgery. (See Celsua, prsef.) And, in re- 
gard to the employment of abstinence, the rules 
of Hippocrates for the treatment of a patient af- 
fected with varix or aneurism are precisely the 
same as those of Valsalva ; that is, dieta qua cjuam 
siccisimus et exsanguissimus fiat. (De Morbis, 
lib. i. sec. x.) 

Man is thus sometimes subjected to the effects 
of abstinence by the prescription of the physician. 
Those effects are sometimes carried to the last 
extremity by accident or calamity ; sometimes by 
obstruction in the oesophagus ; and sometimes by 
the phrensy or monomania of the patient. In 
these several cases, we have, therefore, the oppor- 
tunity presented to us of observing the effects of 
the privation of food on the human subject. The 
investigation has been made still more complete, 
by experiments upon the lower animals. (See 
Rechcrches sur la Digestion, par Tiedemann et 
Gmelin, pp. 91, 160.) In order that we may 
give as practical and useful a view of this subject 
as possible, we shall treat of it under three heads : 
— 1. Of the curative effects. 2. Of the morbid 
effects of abstinence employed as a remedy. 3. 
Of the morbid effects of famine in the other cases 
to which we have alluded ; and, lastly, of the pro- 
per mode of treatment. 

Curative Effects of Abstinence. — Ri- 
gid abstinence is a most powerful remedy in all 
acute dieases. It should, in such cases, be car- 
ried far beyond the degree prescribed as a 
part of the antiphlogistic regimen ; the object 
being not so much to avoid stimulus, as to in- 
duce actual lowness, to subdue the powers of the 
system. 

Abstinence is also a valuable remedy in many 
of the more chronic forms of disease : a state of 
extreme inanition of the stomach not only enfee- 
bles the circulation, but acts most powerfully upon 
the absorbent system. With this view it has been 
proposed to institute a system of rigid abstinence 
in cancer : it might probably be more successful 
in some kinds of dropsy. 

An obvious application of abstinence, as a rem- 
edy, is that made in cases of disorder or disease 
of the stomach itself. These affections are so con- 
stantly the effects of improper food, that, to change 
the diet is obviously but to remove the most usual 
cause. To withdraw food nearly altogether for a 
time would, doubtless, be to employ an actual 
and powerful remedy. This is so evident, and 
vet the facts in illustration are so few in number, 
that we cannot but recommend the subject for fu- 
ture inquiry. If a joint be morbidly affected, we 
enjoin the most absolute repose. The value of a 
well-regulated but rigorous abstinence in cases of 
disorder or disease of the stomach itself, and of 
some of the chylopoietic viscera, especially the 
liver, would, doubtless, be equally great This 
eubject has been well touched upon by Dr. J. John- 
son ; and the writer of this article can add his 
testimony to the beneficial effects of abstinence in 
the cure of these diseases. 

It is impossible to refer to the subject of the use 
of abstinence as a remedy in disorders or diseases 
of the stomach, without recalling to our minds the 
services which .\T. Broussais has rendered to this 
department of medicine : the diite absolute, or 
extreme abstinence, recommended in gastritis by 
that author, is, assuredly, a far more natural and 



appropriate remedy, than the mistaken adminis- 
tration of drastic purges, too much employed in 
this country. 

The next object in enjoining abstinence, is to 
reduce the mass of solids and of fluids. Absti- 
nence is, therefore, the most direct remedy for 
plethora. This point has been ably treated of by 
Dr. Barlow, of Bath, in his Treatise on the Bath 
Waters. See the article Antiphlogistic Regi- 
men. 

The case which next presses itself upon our 
notice, in regard to abstinence as a remedy, is 
that of disease, or tendency to disease, within the 
head. The immediate threatening of apoplexy 
must be treated by active blood-letting; but the 
remedy for the permanent disposition to this dis- 
ease is the most strict abstinence. The most 
rigorous system of weighed or measured portions 
of the least nutritious and least stimulant kinds 
of food is to be enforced. 

We must now add a few words upon the cele- 
brated use of abstinence in diseases of the heart 
and arteries, in the hands of Valsalva, as described 
by Morgagni, (lib. ii. ep. xvii. § 30,) from the 
account given to him by Stancarius. Sufficient 
blood having been taken, Valsalva ordered the 
food and drink to be daily diminished, until it was 
reduced to half a pint of gruel in the morning, 
and less than half that quantity in the evening ; 
to this water alone was added, and that in a cer- 
tain measure only, medicated by the addition of 
quince, See. When the patient was, in this man- 
ner, emaciated, and so debilitated that he could 
not raise his hand from the bed, the diet was 
slowly and moderately increased, so as just to 
maintain power enough for raising the body. In 
this manner these formidable diseases were cured. 
It is confessed, (§ 31,) that some thought the 
cure of Valsalva worse than their aneurism. But 
it was argued that that which was not done early 
in the disease, with the hope of cure, might be- 
come necessary during its progress, without such 
hope, from the incapacity for swallowing. 

Having thus noticed the principal applications 
of abstinence in the cure of disease, we. pass on 
to describe its morbid effects when inappropriately 
or improperly applied. 

2. Morbid, effects of abstinence. — The 
morbid effects of abstinence usually steal on the 
patient, and even the physician, imperceptibly. 
The excessive privation of food is unnatural, and 
therefore not to be borne long with impunity. If 
M. Broussais has, as we have stated, done much 
good, he has, also, been the author of much mis- 
chief. He has passed from extreme to extreme, 
and, in removing irritation, he has frequently in- 
duced a state of exhaustion not less painful and 
perilous. Interesting accounts of such events 
have been published by M. Barras and M. Cafort. 
(See the Med. Chir. Rev. for Jan. 1, 1831.) 
Still more recently the subject has been treated, 
at considerable lertgth, by M. Piorry. (Procedi 
Opiratoire, &c, Paris. 1S30, p. 368.) 

Having referred such of our readers as may 
desire to enter more fully into the subject for 
themselves, to these latest sources of information, 
we purpose to subjoin our own remarks. We 
think, in the first place, that the effects of extreme 
abstinence and its concomitant exhaustion have, 
generally speaking, not been understood ; and, in 
the second, that the morbid effects of abstinence 



44 



ABSTINENCE. 



have, more frequently than is supposed, arisen | 
from its misapplication. 

The first part of the series of the effects of 
abstinence consists in simple debility and emacia- 
tion. The countenance becomes pale, and the 
expression languid ; the muscles of voluntary 
motion become thinner and feebler ; the pulse 
feebler and smaller. The second part of the 
series is different. The pulse is augmented in 
frequency ; there is often palpitation of the heart, 
alternately with syncope ; and there is pain of 
the head, or delirium ; symptoms which might be 
mistaken, by the inexperienced or unwary, for 
those of increased action and power, whereas they 
are but the feeble flashes or glimmerings of a light 
ready to become extinct. 

Such a transition in the effects of abstinence 
is frequently the consequence of an undue ad- 
ministration of this remedy ; still more frequently, 
however, it arises from its inappropriate applica- 
tion. When cases of irritation are mistaken for 
those of inflammation, the morbid effects of ab- 
stinence are particularly apt to occur. The for- 
mer disease neither requires nor bears the remedy; 
whilst, in inflammation, it is both essential to the 
cure of the disease and well sustained by the 
patient. This is a point which requires to be 
well investigated. The ancients, and especially 
Celsus, speak of a principle of encouragement in 
the sick which they expressed in these words — 
difficuller ferre morbiim, (lib. iii. § 3.) There 
is another principle not less important, — diffi- 
cultir ferre hkmkdia. It would be difficult to 
induce the morbid effects of abstinence when there 
is a tendency to apoplexy ; but it would be very 
easy to do so if palpitation, or some other symp- 
tom of gastric irritation, were mistaken for dis- 
ease of the heart, or for inflammation. 

3. Effects of famine. — In order that our 
detail of the morbid effects of abstinence may be 
the more complete, we subjoin a more detailed 
account of the series of phenomena in those cases 
which have been continued to extremes. 

The first case in point we extract from the 
recent excellent work of M. Andral. (Precis 
<T Anatomic Pathologique, torn. ii. p. 769.) A 
man, addicted to drunkenness, was cast into pri- 
son for theft, and reduced, at once, to a diet of 
bread and water. After the first week, a disorder 
of the intellectual faculties took place ; his coun- 
tenance became pale and expressive of languor, 
his flesh wasted, and his strength declined \ his 
nights were sleepless ; shortly afterwards there 
was delirium, which was mild at first, but subse- 
quently furious. The prisoner was now allowed 
brandy. The cerebral symptoms disappeared, and 
the flesh and strength returned. The effects of 
abstinence and of an amelioration in the diet are 
so obvious in this brief case that it is full of in- 
struction. Abstinence and excess induce similar 
symptoms and effects ; a fact which cannot be too 
deeply impressed upon the mind of the young 
practitioner. 

Dr. P. M. Latham's interesting account of the 
epidemic at the Millbank Penitentiary is full of 
facts which bear upon the same point. We refer 
our readers to it for much information. The late 
Dr. Gooch observes, in regard to this epidemic, 
<hat " the prisoners were suddenly put opon a 
diet fiom which animal food was almost entirely 
Excluded. An ox's head, which weighs eight 



pounds, was made into soup for one hundred peo- 
ple which allows one ounce and a quarter ot 
meat to each person. After they had been living 
on this food for some time they lost their colour 
flesh, and strength, and could not do so much 
work as formerly." "At length this simple 
debility of constitution was succeeded by various 
forms of disease : — they had scurvy, dysentery, 
diarrhoea, low fever, and, lastly, afleetions of the 
brain and nervous system." The affections, 
"which came on during this faded, wasted, 
weakened state of body, were hcad-ach, vertigo, 
delirium, convulsions, apoplexy, and even mania. 
When bleeding was tried, the patients fainted 
after losing five, four, or even fewer ounces of 
blood." On examination after death, " there was 
found increased vascularity of the brain, and 
sometimes fluid between its membranes and in 
its ventricles." (Account of Diseases peculiar to 
Women, p. 150.) 

Interesting cases of abstinence are recorded, 
with the full detail of its symptoms, by Dr. Carrie, 
(Medical Reports, Ed. 4, vol. i. p. 304,) and by 
Dr. Willan, (Miscellaneous Works, by Dr. Ashby 
Smith, p. 437.) To these cases we refer oui 
readers ; extracting only what will be sufficient 
to portray the usual character of the late symp- 
toms in the case of inanition, and lead to the due 
distinction between the symptoms of disease of 
the nervous system, which arise from it, and those 
which depend upon a primary disease of the brain 
itself; for the case of extreme abstinence or famine 
affords a remarkable instance of the singular 
effects of exhaustion, and their similarity to those 
of diseases of a totally opposite nature and origin. 

Dr. Currie describes the effects of inanition in 
a case of obstructed oesophagus, as involving the 
following circumstances : — 

The patient's age was 68. The obstruction in 
swallowing gradually increased from the begin- 
ning of August, and on the 1st of November it 
was complete. The following plan was adopted : 
each morning, at eight o'clock, he had a clyster 
consisting of eight ounces of broth, two yolks of 
egg, and forty drops of laudanum ; this was re- 
peated at three p. m., and at nine p. m., with 
thrice the quantity of laudanum. Previously to 
the evening draught, a bath was used, consisting 
of one-fourth part of milk, and three-fourths of 
water, at 96°. In a few days the clysters were 
augmented in quantity, and eight ounces of wine 
were added, with an increased dose of laudanum. 
This plan was continued until the second of 
December. The rectum then ceased to retain 
the clysters, and their employment was relinquish- 
ed. In spite of these plans the emaciation was 
rapid : the patient had weighed 240 lbs. when in 
health ; on the 20th of November, he weighed 
154 lbs. ; and on the 25th, 149 lbs. only. 

The pulse, during the month of November, 
was that of health ; on the first of December, it 
became small and frequent ; on the second, it was 
still more frequent though stronger, with delirium, 
and the case resembled the last stage of fever. 
" During this delirium, a perpetual and indistinct 
muttering occurred, with great restlessness and 
agitation ; the surface and extremities were some- 
times of a burning heat, sometimes clammy and 
cold. The eyes lost their common direction the 
axis of each being turned towards the nose. In 
this state, however, the sensibility of the retina 



ABSTINENCE — A CHOR. 



45 



was not impaired, but rather increased, for he | 
screamed out on the light of the window being 
admitted, to which before he had been accustom- 
ed. At this time also the sense of touch seemed 
more than usually acute, for he appeared disturb- 
ed with every accidental breath of air. The deli- 
rium and the. derangement of vision commenced 
nearly together, but we observed the derangement 
of vision first. On the first of December he com- 
plained that he sometimes saw double ; but it was 
not till the succeeding day that any considerable 
incoherence of mind was observed. The pulse 
became feeble and irregular on the fourth ; the 
respiration, which had been singularly undisturb- 
ed, became laborious ; the extremities grew cold ; 
and in ninety-six hours, after all means of nutri- 
tion as well as all medicine had been abandoned, 
he ceased to breathe." During the first periods 
of this case there was little complaint of hunger 
or thirst ; there was a stool, of a solid form, pale 
colour, but natural fcetor, with each fifth glyster. 
The spirits were even, and the nights good. 

Dr. Willan's case was one of monomania. He 
visited the patient on the 23d of March, 1786, on 
.the sixty-first day of his fast. His emaciation 
was extreme, and he laboured under great imbe- 
cility of mind ; the eyes were not, however, defi- 
cient in lustre, and the voice remained clear and 
sound. He was directed to drink a pint of barley 
water, and two cups of panada, which agreed. 
He had a little fever in the first part of the night, 
but slept better than usual. On the 24th he had 
some mutton-tea; the pulse was small and tem- 
perate. On the 25th he took a pint of milk for 
breakfast ; a pint of mutton-broth boiled with 
barley for dinner, and as much rice-milk for sup- 
per, at his own request. He had considerable 
cravings for food all the day. In the morning of 
the 26th he drank tea, and ate a great quantity 
of bread and butter, which he got from off the 
table in the nurse's absence. Some time after he 
became sick, and vomited once or twice without 
much straining. About noon he had a figured 
natural stool, and presently afier two or three 
loose motions. His skin was always dry. In 
the evening he was apparently much better ; the 
pulse ninety and firmer. On the 27th he took a 
little light bread pudding at dinner, and had two 
eggs for supper ; he rested well and was cheerful. 
On the 28th he seemed better ; he had not slept 
well, however, nor had a stool. On the 29th the 
scene was entirely changed ; he began to lose his 
recollection in the preceding evening ; and before 
midnight became quite frantic and unmanageable. 
His pulse was increased in frequency, with con- 
siderable heat on the skin, and tremors. He con- 
tinued raving, and talking very incoherently, as 
he had done during the night. A strong purga- 
tive draught, and two clysters administered in the 
course of the day, produced but little evacuation. 
He remained nearly in the same state of mind 
as above-mentioned, scarcely ever sleeping, and 
taking very little nourishment, till the 2d of April, 
when a considerable quantity of loose feculent 
matter was brought away by a clyster. Soon 
after he became sullen, and took no notice of 
what passed about him. He was removed at this 
time into the country, so that he was not seen 
again till the 6th of April. He appeared then 
; emaciated to a greater degree, if possible, than at 

ii he first. His pulse was small and feeble, beating 



120 strokes in a minute. April 7th and 8th ha 
took whatever nourishment was offered him ; 
knew those around him, and spoke sensibly, but 
faintly. On the 9th, in the morning, he died 
quite exhausted. 

The case of abstinence affords a beautiful illus- 
tration of the fact, that cerebral symptoms, resem- 
bling those of increased action, do also arise from 
the opposite state of the brain and of the system. 
The effects of exhaustion frequently stimulate 
phrenitis in adult age, and hydrocephalus in in- 
fancy, and it requires the utmost attention and 
sagacity to distinguish them. 

4. Mode of Treatment) — The treatment of 
the morbid effects of abstinence, like the treatment 
of the effects of exposure to severe cold, consists 
principally in the cautious re-administration of the 
natural stimulus. All solid food must be avoided 
at first, and especially milk, which becomes solid 
in the stomach, and is more difficult of digestion 
than other solids from being unmasticated. 

A little thickened broth should be given at 
intervals of four hours, and the quantity very 
gradually increased; and the bowels should be 
carefully relieved by enemata of barley-water. 

No one can read the case of Dr. Willan without 
being impressed with the conviction that the 
treatment was most injudicious. To allow three 
pints of food, — milk, broth, and rice-milk, on the 
third day, after an abstinence of sixty days, was 
quite preposterous. One-third of this ration would 
have been far too much ! 

There is another aspect in which the effects of 
abstinence and their treatment may be viewed. Mr. 
Hunter observed, (Animal Economy, pp. 114, 
1 15,) that if an animal be enfeebled by abstinence, 
its power of maintaining its temperature is also 
lessened. It occurred to the writer of this article 
to witness the same fact : some white mice had 
been neglected, and passed upwards of forty hours 
without food ; they had become torpid and cold ; 
by being held in a warm hand they were perfectly 
restored to life and activity before a morsel of food 
had been administered. From these facts we may 
deduce the inference, that to administer warmth 
is one of the most efficacious modes of remedying 
the effects of abstinence. 

A third remedy is also very important. It 
consists in assiduous frictions. In cases of absti- 
nence the powers of the circulation are greatly 
enfeebled. The most direct mode of restoring 
these powers, after the administration of food and 
warmth, is friction in the course of the venous 
blood. This remedy, therefore, must not be neg- 

Iected - Marshall Hall. 

ACHOR, like most of the terms used to denote 
the morbid appearances presented by the skin, had 
no definite meaning before the time of Willan. 
By the word a%iopcs, Galen and the ancient writers 
who followed him understood " ulcerations pecu- 
liar to the hairy scalp, discharging, from very 
small pores, a viscid ichor, consequent to pustules." 
They were considered by them as a smaller spe- 
cies KT/piov, or favus, from which the latter only 
differed in exhibiting larcrer perforations, and in 
discharging humour similar in colour and consis- 
tence to Hymettian honey. Alexander Trallianus 
and Actuarius first distinguished the pustules 
from the ulcerations in which they terminate. 
The Arabians, simply translating Galen, described 



46 



the achores and favi under the titles of alsahapba, 
or alsahaphati, and alsahara. By the early modern 
writers, achores — manantia ulcera capitis — were 
confounded with tinea ; and in this sense the 
term is used even by Plenck. But, by the greater 
number of writers of the eighteenth century, it 
was separated from favus and tinea, and considered 
as synonymous with porrigo larvalis $ of which 
disease, however, Bateman, as well as Biett, is of 
opinion that achores do not constitute the elemen- 
tary form. We are disposed to think that Alibert, 
in distinguishing from that affection a disease, 
tinea mucijlua, which had generally passed under 
the same name, has removed a difficulty which 
might have been inconvenient to pathologists, and 
has pointed out the disease to which the achores 
most properly belong. 

According to the definition of Willan, "Achor 
is a small acuminated pustule which contains a 
straw-coloured matter, having the appearance and 
nearly the consistence of strained honey. It 
appears most frequently about the head, and is 
succeeded by a thin brown or yellowish scab." 
The matter contained in the pustules does not 
concrete and form a crust, but the pustule breaks 
and is succeeded by small circular ulcerations, 
from which a thin glutinous or oily mucous fluid 
exudes, sometimes in considerable quantity, and 
sometimes forming white or yellow scabs, more or 
less moist. 

The achor is distinguished from the other pus- 
tules as follows: — from the psydracium, by 
being more elevated, more distinctly circumscribed, 
and less generally grouped and confluent ; from 
the favus, by being smaller but more pointed, and 
by not being followed by the characteristic yellow 
sulphur-coloured indented scab (deprimies en go- 
det) which explains and describes the term ; from 
the phlyzacium, l>y being smaller and destitute 
of its elevated and inflamed circular base ; and 
from the varus, (which, for reasons hereafter to 
be assigned, we shall include amongst the pus- 
tules) by being succeeded by a scab or ulcer in- 
stead of a tubercle. 

Achor is a cutaneous affection peculiar to in- 
fancy and childhood, and constitutes the elemen- 
tary form of some porriginous diseases ; but at 
that period of life occasional eruptions of achores 
appear from time to time without amounting to a 
disease. These seem to be connected with a 
plethoric state of the body in general, or of the 
abdomen in particular, or with derangement of the 
alimentary canal, and frequently co-exist with a 
disordered state of the urine. They are most 
effectually both relieved and prevented by mild 
alterative doses of the pulvis hydrarg. cum creta, 
followed by small doses of rhubarb, with either 
soda or magnesia. rn j "Ponr) 

<iCNE. — By this term is understood a chronic 
affection of the skin, characterized by small pus- 
tules, generally distinct, having their base more or 
less hard and of a deep red colour, which, after the 
suppuration of the pustule, generally imperfect, 
becomes a small hard, red, circumscribed tubercle, 
almost indolent, suppurating or resolving always 
very slowly. 

Among the best writers on cutaneous diseases 
there exists a difference of opinion as to the class 
to which acne most properly belongs, arising not 
*■> much from the difficulty of determining the 



ACNE. 

Mature of the vari, as from observing th f 1, \- i r n .. thfi 
different stages of their progress. Pienck Willan, 
and Bateman, considering them as tubercles, have 
placed the diseases of acne in that class, whist 
Alibert and Biett have arranged them with the 
pustular diseases. Any one who has observed 
the progress of this eruption with sufficient at- 
tention, will be disposed to coincide with the last- 
named authorities ; for the circumscribed indu- 
rations, or tubercles, which are so constantly 
observed in this affection, are the consequences of 
pustules, and do not constitute the elementary 
form of the eruption. 

Whilst pathologists have been divided upon the 
form of this eruption, another difference has arisen 
concerning the seat of it, whether it is a disease 
of the cellular texture of the corion, or peculiar to 
the sebaceous follicles, originating in their obstruc- 
tion and inflammation. This latter cause of the 
pustules of acne had not escaped the observation 
of Willan, for he has made it the characteristic of 
his second species, acne punctata; and Alibert 
has also noticed the disorder of the sebaceous 
glands as a source of similar eruptions ; but Mr. 
Plumbe, in describing this as constantly and 
exclusively the process of the formation of the 
pustule of acne, has given an extent to that opin- 
ion which is not borne out by fact. In justice, 
however to this writer, we must not withhold the 
following dissection of a case of acne rosacea, by 
Gendrin (Histoire Anatomique des Inflamma- 
tions) : "A man of fifty-five years of age, who 
died of an organic disease of the stomach, was, at 
the same time, affected with acne rosacea, which 
occupied the surface of the nose and almost the 
whole of the cheeks. The day after his death the 
seat of the eruption was of a bluish red colour, and 
incisions showed the skin to be thicker and more 
dense than in the natural state. On the surfaces 
of the incisions a number of small round red- 
coloured bodies were observed, which, examined 
by the lens, appeared to be sebaceous crypts, evi- 
dently double their natural size. On the surface 
of the skin were also to be observed the orifices 
of these crypts, more dilated than in the healthy 
state, from which a yellow caseous fluid miuht be 
squeezed. In the rete mucosum of Malpighi was 
seen a closely reticulated structure of blood-ves- 
sels, of a violet-red colour, and the corion gene- 
rally was much increased in vascularity. Exter- 
nally the skin was unequal and elevated by small 
round grains, which were felt more distinctly 
when a detached portion of the skin was pressed 
between the fingers. These bodies were produced 
by the developement and induration of the seba- 
ceous follicles. The general tenacity of the skin 
was considerably diminished." Notwithstanding 
the proof apparently afforded by this dissection, 
we are convinced that the emphragma sebaceum 
is not the most common cause of the pustule of 
acne ; for, although one sometimes finds, particu- 
larly on the face and chin, small pustules which 
are caused in this way, and from which, after the 
pus has been evacuated, a small oval body, formed 
of indurated sebaceous matter, may be expressed; 
and although a morbid accumulation of this mat- 
ter is observed in several cases of acne, yet all this 
is far from proving that this state of the follicles 
is essential to this form of pustule. And there- 
fore, we very often see individuals whose follicles 
are in this state, without presenting any trace of 



ACNE. 



47 



acne ; whilst, on the contrary, we see acne unac- 
companied by this state of the follicles; and when 
they do become complicated together, we never 
see the infarcted follicles become true pustules of 
acne ; for, by compressing the latter at the period 
of suppuration, pus is easily made to escape, and 
not indurated sebaceous matter. Nor is it correct 
to say that the seat of acne is always coincident 
with that of the sebaceous follicles ; for, though 
this may be true as regards the nose and forehead, 
the contrary is the case in other parts where these 
glands most abound, as at the orifice of the meatus 
auditorius externus, in the axilla, or in the parts 
surrounding the nipple, the anus, and vulva. 

Acne is a cutaneous disease which is pretty 
steady and constant in its character, and not like 
many other cutaneous affections, apt to change its 
elementary form for that of another, or to be fre- 
quently complicated with other eruptions ; except 
that in one species of this complaint (acne indu- 
rata) the vari approach to the nature of furunculi, 
and in another (acne rosacea) there is a tendency 
to erythema. We have also sometimes observed 
acne upon the face to co-exist with eczema, par- 
ticularly of the extremities, the hands or legs. 

The opinion which we hold of the nature of the 
elementary eruption of acne will lead us to modify 
the classification of Willan.by placing this disease 
in the order of pustular diseases, and by addin? 
varus to the varieties of pustules. In the subdi- 
vision of the genus we have little alteration to 
propose, except that we should prefer acne folli- 
culuris to acne punctata, as explanatory of that 
species of the disease ; and that as it is our inten- 
tion to distribute the syphilitic eruptions according 
to their external characters, considering the form 
of the eruption to be determined more by pecu- 
liarity of individual constitution than essential to 
the nature of syphilis, we shall have occasion to 
subjoin another species. Were this classification 
perfectly natural, mentagra, or sycosis, ought to 
find its place in this genus ; but not wishing to 
introduce any innovation in the arrangement which 
can be avoided, we shall follow Willan and Bate- 
man in considering it apart. This genus will, 
therefore, consist of the following species : — 

1. Acne simplex, 3. Acne indurata, 

2. follicular is, 4. rosacea, 

5. Acne syphilitica. 

1. Ao'E simplex, — Syn. 'iovOoi (Grec.) ; Vari 
(Lat.) ; Psydracia acne (Sauv.) ; Gutta Rosea 
hereditaria (Darwin) ; Dartre pustuleuse miliare 
(Alibert) -, Die Finnen (Plenck.) 

This species consists in an eruption of small 
vari, appearing chiefly on the face, temples, or 
forehead, upon the shoulders, the upper part of 
the back, or breast. These pustules, which are 
not numerous, are generally observed to succeed 
each other. They go through their course sepa- 
rately, without any symptom of constitutional 
disorder, and generally without any local pain, 
heat, itching, or uneasiness, so that it is not un- 
common to meet with people having a considera- 
ble eruption of vari upon the back, without their 
being aware of it. These pustules first appear 
under the form of small inflamed points, which 
are felt in the skin like small hard seeds, about the 
size of a pin's head ; they continue to enlarge for 
three or four days, and about the sixth or seventh 
day they attain their greatest size, when they are 
red, smooth, elevated, and somewhat acuminated. 



They are hard, tut seldom painful to the touch 
After two or three days more, a small speck of 
yellow matter appears on the apices of some of 
the pustules ; when these break, a thinner mattei 
is secreted which soon dries into a thin yellowish 
scab. After the suppuration is finished, (which, 
in proportion to the size of the pustule, is always 
inconsiderable,) and the scab separated, there still 
remains a red point, a little elevated, which only 
disappears very gradually. At other times the 
redness and swelling continue, and if that is the 
case with a considerable number of the pustules, 
whilst new ones are appearing, the disease ap- 
proaches more or less to the acne indurata. Or 
when the disease has continued some time, a gen- 
eral redness and roughness of the intermediate 
skin takes place from the coalescence of the Li- 
flamed areolas of the pustules. 

Sometimes, however, instead of the pustule; 
appearing in succession, a considerable number of 
them break out simultaneously, covering almost 
the whole surface of the forehead ; a circumstance 
which is most frequently observed in young fe- 
males. And when the pustules exist in a consid- 
erable number, the sebaceous follicles appear to 
suffer a certain degree of irritation, for the skin 
has an oily shining surface ; suppuration is retard- 
ed, and the pus is smaller in quantity, and a very 
thin scab forms, which separates so quickly that 
it is sometimes not observed : or, at other times, 
and more especially when the eruption is seated 
upon the back or shoulders, the suppuration is 
more abundant, and the scab is thicker, but soon 
detached by the friction of the linen. 

This eruption, very correctly delineated in Bate- 
man's LXII. plate, and in the 23d of Thomson's 
Atlas, is very inadequately represented in the 22d 
Plate of Alibert's splendid work. 

The acne simplex, which is rare before puberty, 
occurs chiefly in young people about that age, and 
is very common in young females on the first ap- 
pearance of the catamenia. In some individuals 
this eruption continues for some time to recur, or 
to become more troublesome at the menstrual pe- 
riod, and is not an unusual attendant upon dys- 
menorrhcea : in others, who have it partially, it 
frequently returns at short intervals ; but in others, 
who are more strongly predisposed to it, it is more 
extensive, and never wholly disappears, being 
more or less troublesome at uncertain periods. It 
is a disease, even when present in a very consid- 
erable degree, perfectly consistent with the enjoy- 
ment of good health ; for which reason it was 
formerly considered a salutary effort of nature to 
relieve the constitution. Many people experience 
a decided relief in disorders of the digestive or- 
gans on the appearance of vari ; so that, on many 
occasions, they seem to be critical. And Bate- 
man observes that severe indigestion, or continued 
pains in the stomach, have been immediately re- 
lieved after an eruption of vari; in which instances 
there is occasionally also an eruption of liehe- 
nous papulas on the body and limbs. It appears, 
however, to be most closely connected with an 
imperfect performance of the functions of the 
womb, with a constipated state of bowels, or a 
sluggish state of the secretion of the liver; and 
hence the vari have sometimes been called atra- 
biliary pustules. It does not, like many otbe 
cutaneous diseases, depend upon irritation or an 
irritable state of the mucous membranes of th* 



48 



ACNE. 



alimentary canal, but more often co-exists with an 
atonic state of the digestive organs. But? what- 
ever may be the pathological condition of the body 
upon which it depends, the cause which has un- 
questionably the leading influence upon this com- 
plaint is hereditary predisposition. Sedentary ha- 
bits, an indolent manner of living, extremes of 
diet, spare as well as rich, and anxiety of mind, 
tend to confirm this predisposition ; and wherever 
it exists, trifling causes are sufficient to excite the 
Amongst these may be mentioned errors 
of diet; excesses at table ; violent exercise in hot 
weather, or in heated rooms, especially when fol- 
lowed by cold drinks ; eating cold raw vegetables, 
as cucumbers, turnips, melons, when the body is 
much heated ; exposure to the heat of the sun or 
of the fire ; the application of irritating cosmet- 
ics ; vexation of mind, bursts of passion, or any 
strong mental emotion. 

It would be difficult to mistake the eruption of 
acne simplex, in its pure state, for any other cuta- 
neous affection. Ecthyma is the disease which, 
in appearance, it most resembles ; but the vari of 
acne may easily be distinguished from the phlyza- 
cious pustule of that disease by their smaller size, 
by their slower progress, and by their base contin- 
uing indurated after suppuration : whilst the pus- 
tules of ecthyma are large and superficial, never 
accompanied with chronic indurations, and form 
thick scabs more or less prominent. When the 
eruption of acne simplex has frequently recurred 
in the same part, as on the nose or forehead, the 
skin takes on a general appearance, which, by an 
inexperienced observer, might be mistaken for a 
pustular or the small tubercular syphilitic erup- 
tion ; but the particular red copper-coloured areola, 
and the disposition of the syphilitic tubercles to 
ulcerate upon their summits, will easily distinguish 
them ; whilst the concomitant constitutional symp- 
toms clear up all doubts which might arise. 

Bateman has undoubtedly been guilty of an 
oversight in considering the acne simplex as a 
local disease, and leaving it to be treated chiefly 
by external applications. But in this opinion he 
is, indeed, almost solitary ; for the united experi- 
ence of the best observers is against him. Like 
almost every affection of the skin, when long seat- 
ed in any part, it may persist as a local disease ; 
but in its origin it is strictly symptomatic, and is 
invariably aggravated by any disorder of the func- 
tions of those organs in which it has its source. 

When the pustules of acne simplex are few in 
number, they scarcely deserve any attention, ex- 
cept as symptoms of some constitutional derange- 
ment ; but when they are considerable, they re- 
quire the use of different medical measures, as 
well general as local, on their own account. When 
the disease appears to be connected with an unsat- 
isfactory discharge of the uterine functions, the 
treatment must be directed to this object. In young 
persons of a strong and plethoric constitution, and 
particularly if about the first appearance of the 
catamenia, a small bloodletting will afford the most 
immediate relief; or, if there is pain of the back 
or loins, a few leeches may be applied to each 
groin, the feet may be immersed in a warm salt- 
water pediluvinin, and the bowels preserved in an 
open state by some cooling saline aperient, as the 
sulphate of magnesia dissolved in infusion of roses, 
and acidulated with diluted sulphuric acid, or the 
vul polychrest in combination with very small 



doses of rhubarb. When the patient is more deli- 
cate, the sulphur lotum in combination with mag- 
nesia and rhubarb affords a very safe and satisfac- 
tory remedy. It is conveniently administered as 
follows: — R Sulphur, loti, magnesias a* .~i. ; 
Pulv. rhei. 9i.; Pulv. rod. glycyrrhiz. 3 ss. 
Fiant pulveres sex, quorum unus bis terve die 
sumendus. To this may be added the use ol live 
grains of the pil. aloes cum myrrha at bed-time; 
or, if the patient is pale, and the circulation lan- 
guid, small doses of the sulphas ferri may be com- 
bined with the aloetic pill. If the eruption is ex- 
tensive or obstinate, five grains of the pil. submu- 
riat. hvdrargyr. comp. may be taken at bed-time, 
instead of the aloetic pill. The diet should be 
light, cooling, and easy of digestion ; and wine 
and all heating drinks should be abstained from. 

The same general treatment is applicable to 
young male subjects ; a small venesection, cool- 
ing saline aperients, the powder of sulphur, mag- 
nesia, and rhubarb, and, if necessary, a few grains 
of Plumincr's pill, and a course of decoction of 
taraxacum, with a little sulphate of potass. In 
both cases, after the aperient and alterative reme- 
dies, the diluted mineral acids are useful reme- 
dies. 

The best local application to the eruption in 
the early stage is decoction of bran, decoction of 
the seeds of cucumbers or melons, or the emul- 
sion of bitter almonds. It is not until the erup- 
tion has declined and become chronic, that gently 
stimulating applications are required, and they are 
then of much use. The effect of any irritating 
lotion used in the early state of the eruption, is 
to multiply the pustules ; but after suppuration, 
when proportioned to the sensibility of the local 
affection, they are often of the greatest use. Nor 
in this period of the disease need there be any ap- 
prehension of producing internal disorder by the 
sudden repulsion of these cutaneous eruptions ; 
it is only in the early and active state of the dis- 
ease that headache and disorders of the digestive 
organs have sometimes been thus produced. The 
milder, but sometimes not the less efficacious, 
lotions for this purpose are sulphurous mineral 
waters, a weak solution of sulphuret of potass, (R 
Potassii sulphureti gi. ; Aquas f.Oi.) or the lotion 
which is made by pouring a quart of boiling wa- 
ter upon an ounce of sulphur, and allowing it to 
infuse twelve or fourteen hours. When the erup- 
tion is extensive, the same preparations may be 
used in general baths at 96°, (R Potassii sulphu- 
reti !|iv. ; Aq. c. c. fiat balneum.) Lotions, 
containing alcohol, afford very satisfactory appli- 
cations to this eruption. (R Aqua rosse Oss.; Alco- 
hol. f.3 ii- ; fiat loti o.) The proportion of spirit 
must be diminished or increased according to the 
excitability of the skin ; but it must not be for- 
gotten, that a slight increase of inflammation is 
often advantageously excited by the first applica- 
tion of a moderate stimulus; that this transient 
irritation is overcome by persevering in it ; and 
that, in this way, the skin acquires the power of 
bearing an increased degree of stimulus. The 
efficiency of alcoholic lotions is sometimes in- 
creased, by the addition of a little of the liquor 
ammoniae acetatus, or acetous acid, or subcarbo- 
nate of ammonia. The muriate of ammonia in 
lotion, is sometimes very useful in chronic cases 
of acne simplex. (R Aqua; rosas Oss.; Alumi- 
nis^m- ; Ammonise muriutis gi. ; Potatsii sul- 



ACNE. 



4G 



phureti J}i ;ft. lotw.) When stronger irritating 
remedies are necessary, which is, however, seldom 
the case, muriate of mercury, in small quantities 
may be added to the alcoholic lotions. (R Aqux 
destillat. Oss. ; Alcohol, f.^i.; Hydrargyri chlorid. 
corrosiv. gr. \i.ft. lotio.) It sometimes happens, 
that in old cases of acne simplex, much benefit is 
derived from exciting an inflammatory state of the 
eruption. Bateman mentions a lady who con- 
sidered herself much benefited, after a severe 
inflammation, and even excoriation of the face, 
which had been produced by a poultice of bruised 
parsley. But it is seldom necessary, in this spe- 
cies of the disease, to have recourse to the remedy 
of Ambrose Pare, revived by Darwin, who affirms 
that blistering the whole face, in small portions 
successively, is the most effectual remedy for the 
inveterate forms of this acne. 

The ancients, in the treatment of vari, chiefly 
relied upon external stimulant applications. These 
consisted of lotions and liniments, containing 
vinegar and honey, sometimes combined with an 
emulsion of bitter almonds, and sometimes with 
resin, myrrh, turpentine, and other gums, with 
alum, soap, and Cimolian earth ; or the bruised 
roots of the lily, cyclamen, and narcissus. But 
the fruit of the wild vine (labrusca) is the appli- 
cation which Pliny (Hist. Nat. lib. xxiii. cap. 14,) 
mentions as most especially useful. 

2. Acne Folliculakis, Maggot Pimple. 

Syn. Acne punctata (Willan) ; 'luvOo; (Greco- 
rum); Varus (Latin); Crinones, Crimones (Va- 
riorum Auct.); Grutum milium (Teuton ice); Der 
Gries (Plenck) ; Puncta? mucosa? (Darwin) ; 
Grubs (Anglice); Tannes (Gallici). 

Pustules, having the precise character of vari, 
are observed to have their scat in the sebaceous 
follicles ; sometimes originating locally from the 
accumulation and induration of sebaceous matter, 
causing their obstruction (emphragma sebaceum); 
and sometimes symptomatically, from inflamma- 
tion of the follicles, arising from some disorder of 
the internal organs. When the vari are produced 
by the first named cause, the sebaceous matter, by 
being exposed to the air at the mouths of the fol- 
licles, assumes a black appearance, and the pus- 
tules present a black point on their summit, sur- 
rounded by a very slightly raised border of cuticle. 
This circumstance, which gives sometimes a par- 
ticular feature to the disease, afforded Willan the 
specific character of acne punctata,- but for which 
as this appearance is far from being constant, and 
as pustules have their seat in the follicles without 
presenting it, we have substituted acne follicularis, 
as better explaining the nature of the affection. 

A loaded and obstructed state of the sebaceous 
follicles may exist to a considerable extent, with- 
out inducing inflammation ; and only very minute 
hard white tubercles, of the colour and size of 
millet seeds, are to be observed, from which the 
sebaceous matter being pressed out through the 
circular orifice of the follicle, takes a filiform shape, 
bearing a close resemblance to a maggot. That 
it really owes its form to the manner in which it 
is forced through the aperture of the follicle is 
obvious ; for, if the black spot is ruptured by a 
fine needle, it will be seen to be a mere deposition 
of sebaceous matter of a round form. In this 
state they are commonly known by the name of 
crinones, worms or grubs. [Recently, it has been 
found, that these follicles are occupied by a para- 

VOL. I. — 7 E 



sitic insect, (Acarus folUculorum,) which has been 
found alone or in clusters of several in a single 
follicle. In the perfectly healthy state of the 
follicles, they are few in number ; but when 
sebaceous matter, which seems to serve them for 
aliment, is allowed to accumulate, they abound. 
The insect was first observed by M. Simon, of 
Berlin, and has been since seen and described by 
Mr. E. Wilson, in his work on Diseases of the 
Skin.] As the matter accumulates and hardens, 
it becomes a source of local irritation, and the 
sebaceous crypts, in consequence of distension, 
inflame and form pustules, which suppurate im- 
perfectly. At other times these obstructed follicles 
remain stationary, without ever passing into the 
inflammatory state ; or the accumulation of the 
matter goes on increasing until they form con- 
siderable follicular tubercles, resembling those of 
molluscum,and sometimes tumours of considerable 
size, or, occasionally inflaming, assume the ap 
pearance of indolent boils. 

The disposition of the body to the accumula- 
tion of the sebaceous matter in the follicles of the 
skin is much dependent upon peculiarity of con- 
stitution, but is always very intimately connected 
with a constipated state of the bowels, so that in 
many individuals the necessity for aperient medi- 
cine is indicated by the sebaceous follicles appear- 
ing full or prominent. 

Besides this origin of follicular vari, they may 
also be produced directly without any collection 
of sebaceous matter either by local irritation, in 
which way some kinds of cosmetics seem to act, 
or by inflammation of the follicles arising sympto- 
matically from the irritation of the internal organs, 
as the bowels or the womb. 

The follicular may often be seen mixed with 
the simple vari in this and the other species of 
acne. Of this complication there is a very accu 
rate delineation in Bateman's LXII. plate. 

For the removal of follicular vari, besides the 
general treatment of acne simplex, which is alsr 
applicable here, it is necessary to empty the folli 
cles by mechanical means, either by pressing on 
both sides of the pustules until the hardened 
matter is sufficiently elevated to be taken hold of, 
or by employing a blunt curved forceps for this 
purpose. But when this state of the follicles 
exists, to a considerable extent, nothing so effec- 
tually empties them and clears the skin as the 
vapour bath, followed by the warm sulphurous 
bath. Lotions of sulphuret of potass, with or 
without alcohol, are of great service when the 
disease is of small extent. When the disease has 
subsided, and the state of the skin admits of it, 
general friction with the flesh-brush, a flannel 
glove, or a coarse towel, is of great use. The 
internal remedies most suitable in this complaint, 
are powders of sulphur, magnesia, and rhubarb, 
with an occasional saline aperient. Dr. Under- 
wood recommended the use of a solution of car- 
bonate of potass internally, and Dr. Willan was 
in the habit of occasionally prescribing the o\y- 
muriatic acid ; and there can be no doubt that 
any other medicines which improve the functions 
of the digestive organs and benefit the general 
health, have a considerable influence in correcting 
this unhealthy state of the skin. It is probably in 
this way that the following alkaline tonic, recom- 
mended by Dr. A. T. Thomson, produces its 
effects ; (R Zinci sulphat. gr. xxiv. : Liquori* 



50 



ACNE. 



potassce f.gxii. j solve. Sumantur guttx xxx. 
ex cyatho aquae bis nuotidie.) 

3. AcVV. INDURATA, StOllC-pOck. 

Syn. aW6\ikcs (Hipp.) ; Vari (Latin) ; Dartre 
pustuleuse disseminee(.4/('&eri'); Pustulffi solitariffi 
(Teutonici); Eiterfinnen (Punchy, Pustulaj in- 
flammatoriffi (Lorry). 

In this species the vari are larger, less regular 
in their figure, sometimes ovate as well as conoidal; 
they are deeper seated ; the inflammation of the 
surrounding skin is more extensive ; suppuration 
takes place still more slowly, and is followed by 
thicker scabs and by partial indurations, more or 
less considerable, in the subcutaneous cellular 
tissue as well as in the skin. It attacks the face 
most commonly, but is also very frequently ob- 
served upon the upper part of the back, shoulders, 
and breast, and has sometimes been seen to cover 
the whole posterior part of the trunk. It affects 
chiefly young adults of both sexes, but the severest 
cases are met with in young men. It affects most 
generally persons of gross phlegmatic tempera- 
ment, who have a thick greasy skin : and though 
the strong and robust are more frequently the 
subjects of its attacks, it does not spare the weak 
or exhausted. We have certainly observed it 
more frequently in patients of a scrofulous habit 
than in others. We have known it co-existing 
with a strong family predisposition to mania; and 
it has been observed in connection with the he- 
morrhoidal constitution and pulmonary consump- 
tion. It is sometimes accompanied with symp- 
toms of abdominal derangement ; but it is also 
sometimes the only discomfort of people enjoying, 
in every other respect, perfect health. In persons 
predisposed, it is generally excited by irregularity 
of dint, by cold food or drink when the body is 
heated, and sometimes it is developed by external 
irritating applications, as a blister. 

This complaint presents itself in very different 
degrees of intensity. Sometimes it is very slight; 
a few red inflamed points show themselves in the 
forehead, temples, the upper part of the cheeks, or 
over the angles of the lower jaw ; these become 
pustules of a bright rose colour, which, rising 
slowly, only after two or three weeks, end in sup- 
puration, or sometimes never arrive at that state. 
The pustules when red are sore and tender to the 
touch, but as they decline they become livid and 
less painful. These are succeeded by other pus- 
tules. After suppuration, the skin on which they 
are seated remains hard and of a bright rose red, 
and the subcutaneous cellular 'tissue assists in 
forming tubercles, or chronic indurations. In this 
manner, a certain number of pustules having suc- 
ceeded each other, the affection gradually sub- 
sides. 

But, in general, the disease is much more 
severe ; the whole face is covered with irregular 
bright red pustules and livid red tubercles ; they 
are particularly large and numerous on the rami 
of the lower jaw and under the jaw ; on the 
temples and cheeks ; and smaller but not less 
thickly spread upon the nose and forehead. These 
tubercles themselves often suppurate, forming 
superficial indolent abscesses covered with skin 
of a livid red colour. They seldom point or find 
issue for their contents spontaneously, but occa- 
sionally require to be discharged by the aid of the 
lancet, and then the wound heals slowly, leaving 
a livid indented mark, which never disappears. 



The intervals of the tubercles are studded with 
pustules in different stages of their progress, cither 
just beginning to appear, in a state of suppuration 
or covered with a scab, with red spots distributed 
amongst them, so as sometimes to give a general 
red appearance to the whole surface of the skin. 
Occasionally a number of black points, marking 
infarcted mucous follicles, or true follicular vari, 
are to be observed, here and there, in the intervals 
between the tubercles and pustules, but chiefly 
upon the sides of the nose, cheeks, and forehead. 
The skin is greasy and shining, and the whole 
face much swollen and inflated, giving the patient 
a most disagreeable aspect, which is very accu- 
rately represented in Bateman's LXIII. plate. 

The pustules of acne indurata often leave traces 
which it is impossible to efface, the skin being 
marked with many very small scars, the effects of 
former eruptions of this complaint, more or less 
frequently repeated. 

Though this species of acne attacks frequently 
both the face and back at the same time, it some- 
times spares either one or the other, but in cither 
case the disease is of long duration and tedious ; 
and whether it terminates spontaneously or by the 
power of art, the process is only completed very 
slowly, and patients remain very liable to a re- 
lapse. 

Notwithstanding the severity of the eruption, 
the patient may enjoy good genoral health, and 
attend to all his wonted avocations, unless he may 
have to complain occasionally of headach, or a 
disagreeable sense of heat in the face ; and it has 
been observed, that if a fever, or other severe dis- 
ease, should take place, the eruption often sub- 
sides or disappears ; so that its recurrence under 
such circumstances is to be deemed a sign of 
returning health. Batcman has seen the erethism 
of a mercurial course, administered for other pur- 
poses, occasion the disappearance of this acne, 
which returned with the restoration of flesh and 
strength, after the omission of the medicine. And 
we have observed that in those cases in which the 
disease is compatible with otherwise good health, 
it is also invariably the most difficult to cure. 

When acne indurata is severe or of long dura- 
tion, it is a disease most difficult to subdue, and 
often resists the most skilful and the most perse 
vering treatment. If the eruption is sudden 01 
extensive, and appears in a subject of sufficient 
strength, nothing makes so decided an impression 
upon it as venesection ; and, even in delicate sub- 
jects, advantage may be derived from the detrac- 
tion of a few ounces of blood. In the inflamma- 
tory state of the disease, cooling saline purgatives, 
with a mild alterative mercurial pill at bed-time, 
and the antiphlogistic regimen form the essential 
parts of the constitutional treatment. As the 
disease declines, or becomes chronic, the mineral 
acids are often used with great advantage ; and 
the internal use of the sulphureous mineral waters, 
as those of Harrogate, are amongst the most suc- 
cessful remedies. Dr. Bateman thinks that ad- 
vantage has been derived from the internal use 
of small doses of soda, sulphur, and antimony, 
assisted by proper external treatment. Neither 
purgatives nor the antiphlogistic regimen should be 
continued longer than the first active state of the 
disease. On the contrary, it is frequently of ad- 
vantage to have recourse to mild tonics and alkalis- 
and, on the same occasions, the greatest benefit 



ACNE, 



51 



has been derived from changing from a poor to a 
more generous diet. Lorry relates the case of a 
water-drinking monk, whom he relieved of this 
complaint by the moderate use of wine. The 
constitutional disease with which this complaint 
appears to be most connected is atonic dyspepsia, 
with a constipated state of bowels ; it is, there- 
fore, obvious that a plain moderate diet of animal 
food is more likely to agree than raw vegetables, 
cresses, and vegetable acids, used under the notion 
of correcting the scorbutic state of the humours. 

[In some obstinate cases of the different forms 
of acne, great benefit has resulted, as in other 
chronic cutaneous cachexies, from a thorough 
change of diet, and especially from putting the 
patient on the use of saccharine matter between 
the meals, so as to modify the condition of the 
chyle, and through it that of the blood and of 
the tissues. An ounce and a half of simple syrup 
may be given with this view about three hours 
after each meal. With the syrup may be associated 
the iodide or ioduretted iodide of potassium, in the 
form of the liquor iodini compositus (gtt. x — xx 
ter die). By a perseverance in this course for 
eight or ten weeks, some very obstinate cases have 
yielded, See Dunglison's Practice of Medicine, 
2d. edit., p. 129. Philad. 1844; and his Ele- 
ments of Therapeutics and Materia Medica, Vol. 
2, p. 315. Philad. 1843.] 

But constitutional treatment would be of little 
avail without the assistance of local means for 
accelerating the progress of the pustules, or for 
promoting the resolution of the tubercles. In the 
early stage of the eruption, mild emollient appli- 
cations are most suitable, such as demulcent 
decoctions or poultices, which, if there is pain, 
may be made with the decoction of poppy heads. 
When the pustules have suppurated, and are slow 
in discharging themselves, it is advisable to apply 
to them, as Turner recommends, the common 
principles of surgical treatment. After the pus- 
tules have discharged their contents, either spon- 
taneously, or by means of the lancet, stimulating 
alcoholic lotions, containing a small quantity of 
corrosive sublimate, are chiefly to be relied on, 
such as have been mentioned for the severer cases 
of acne simplex. In the hospital of St. Louis, 
at Paris, the greatest advantage has been derived 
from rubbing the pustules, as well as the tuber- 
cles, with the following ointment : R. Hydrar- 
gyri ammoniat. J}i. ad gi. -, Adipis, gi. But 
of all the preparations for promoting the resolu- 
tion of the tubercles of acne indurata, none are, 
according to M. Bictt, to be compared to the 
iodide of sulphur, mixed with lard. (K. Sul- 
phur, iodid. gr. xii. ad gr. xxiv. ; Adipis, gi.) 
M. Biett employs this remedy in the wards of the 
Hospital of St. Louis with decided benefit. In 
some severe cases of acne indurata submitted to 
the friction of ioduret of sulphur, the tubercles 
were resolved with astonishing rapidity. But the 
good effects of all these means are very much 
promoted by the use of the vapour bath, and 
more especially of the douche of vapour, directed 
for twelve or fifteen minutes upon the eruption. 

It is principally in old chronic cases of the acne 
indurata, where the local affection has completely 
established itself, that it may sometimes be neces- 
sary to have recourse to means for changing 
entirely the action of the part j and for this pur- 
pose, blisters, used by Ambrose Pare, under the 



notion of drawing out the peccant humours, and 
revived by Darwin, have been frequently used in 
the Hospital of St. Louis, and have been found 
eminently useful. [Solid nitrate of silver has 
been rubbed over the parts, and they have been 
brushed over with one of the concentrated mineral 
acids with a similar object.] 

During any recurrence of a considerable fresh 
eruption, the means adapted to the chronic state 
of the disease must necessarily be suspended, and 
recourse had to the constitutional and local means 
suited to its inflammatory state. 

M. Biett has found that when the disease has 
disappeared, a lotion, or douche of cold sulphur- 
ous water is of great use in establishing the cure, 
and in preventing a return of the eruption. 

4. Acne rosacea, carbuncled face. 

Syn. Zevtov (Grec.) ; Varus (Roman) ; Gutta 
rosea et rubedo (Auctorum) ; Gutta rosacea 
cenopotarum et hydropotarum (Teutonice): Kup- 
ferbandel (Plenck) ; Bacchia (Linn.) ; Gutta 
rosea hepatica (Darwin) ; Herpes pustulosus 
gutta rosea, Dartre pustulcuse couperose (Ali- 
bert) ; Ionthus corymbifer ( Good) ; Saphirs, 
Goutte rose, couperose (French) ; Roth-gesicht, 
Roth-nase (German) ; Red pimpled face. 

In a correct pathological nomenclature, as the 
last species might with greater propriety be term- 
ed acne furunculus, being a complication of the 
varus with phlegmon, or inflammation of the 
subcutaneous cellular tissue, so this species would 
be more accurately distinguished under the name 
of acne erythema, the pustules of acne being 
combined with an erythematic inflammation of 
the skin. In this respect, as regards the local or 
external disease, acne rosacea differs from the 
other species, the vari sometimes preceding and 
developing the erythema, and the erythema, on 
the contrary, being sometimes the occasion of the 
vari. From this circumstance has arisen the dis- 
tinction of gutta rosea, observed by Nicolaus 
Floientinus, Ambrose Pare, Astruc, and Plenck, 
dividing it into species, under the terms of sim- 
plex, or pure erythema, — pustulosa and bacchia- 
lis, the acne rosacea of Willan, — and squamosa 
ulcer ans and varicosa, the sequelae of obstinate 
forms of that disease. 

The nose is, commonly, the first seat of this 
affection. In persons predisposed, who are gen- 
erally of the middle age, after any exciting cause, 
as a full meal, heating drinks, or indigestible sub- 
stances, the extremity of the nose becomes of a 
deep red colour, more or less intense, which at 
first gradually subsides with the removal of the 
exciting cause ; but, at length, by repetition, 
grows to be habitual. In this red shining ap- 
pearance of the nose, some elevated points of a 
brighter red colour, sometimes distinct, sometimes 
in groups, are afterwards observed. These points 
enlarge, becoming pustules, which suppurate at 
their summits ; but the suppurative process is 
always imperfectly established, forming seldom 
more than a small white acuminated point on the 
apex of the pustule, which makes a striking con 
trast with the dark damask red colour of the pus- 
tule, an appearance which is well represented in 
Alibert's XXI. plate. This white point of the 
pustule bursts and forms a thin white scab, which, 
detaching itself, leaves beneath it a hard phyma- 
tous tubercle. These pustules succeed each othc 
I and in this manner the disease perpetuates itself 



52 



ACNE. 



Sometimes the disease is confined exclusively to 
the nose, which, from the repetition of this mor- 
bid process, and the successive formation of tuber- 
cles, increases very considerably in size, being 
covered with knobs and asperities, whilst the 
blood-vessels of the surface of the skin are seen 
enlarged, and the small veins appearing varicoscd, 
have the appearance of bluish lines, strongly con- 
trasted with the general red colour of the surface ; 
or the intermediate skin is striated with reticula- 
tions of enlarged cutaneous veins, resembling an 
injected membrane, an appearance which is cor- 
rectly delineated in Bateman's LXIV. plate. M. 
Alibert thinks he has observed, that the right side 
of the nose is more liable to be affected with this 
species of acne than the left, a circumstance which 
he connects with the influence of the state of the 
liver upon this disease. More generally the size 
of the nose is not increased, but its form only 
altered ; and the disease extends itself to the 
cheeks, forehead, and chin, so as sometimes to 
cover the whole face. The red colour of the skin, 
which is always more remarkable after dinner, or 
in the evening, than in the morning, is not any- 
where equal in degree, but is always more so in 
the seat of the pustules. The disease may cease 
and return in different degrees of intensity ; but 
after it has continued for some time, the surface 
of the skin becomes uneven and rough, and if the 
disease should even disappear, the skin never 
entirely recovers its natural state. 

In general this eruption produces little discom- 
fort of feeling in proportion to its deformity, sel- 
dom more than a slight momentary itching ; but 
some persons have the face in a very irritable 
state, with the sensation of heat and burning, 
being frequently obliged to bathe the face in cold 
or tepid water for relief. After eating, drinking, 
or any moderate exercise, they feel a sudden glow 
of heat in the face ; but it is chiefly when they 
approach the fire that they suffer most ; it pro- 
duces in them a sensation of pungent heat, or of 
burning and itching. 

Hereditary disposition is, unfortunately, one of 
the most common predisposing causes of this dis- 
ease, and one which sometimes inveterately ad- 
heres to many successive generations. Alibert 
traced the disease, in one family, through four 
generations. This predisposition frequently shows 
an affinity with that of scrofula, but is always in- 
timately connected with the state of the functions 
of the abdominal viscera, and hence causes tend- 
ing to establish an unhealthy state of these is 
liable to induce this predisposition. For this rea- 
son, the indulgences of the table, in eating as 
well as in drinking, violent emotions, or long and 
intense exertions of the mind, sedentary occupa- 
tions, and much watching, are amongst the most 
frequent causes of it. Persons of middle age are 
consequently most liable to it ; and it is most fre- 
quent in men of it hemorrhoidal constitution, and 
in women at the critical period of life, or in such 
as suffer from disorder of the uterine functions. 
Notwithstanding the difference of habits, it seems 
equally common to both sexes. Sometimes it 
shows itself, or is increased, during gestation ; 
but in other circumstances, it has been observed 
to disappear during pregnancy, and return after 
parturition. Besides these causes, anything which 
favours or determines the afflux of blood to the 
bead, increases the tendency to this complaint. 



It will, therefore, be easy to understand, from the 
causes just assigned, why it should be met with 
amongst men of letters, lawyers, merchants, and 
gamesters, and in public offices , among women 
employed in drawing, painting, and tambouring, 
and in those whose avocations oblige them to 
keep the head in a depending position. It is not, 
however, to be forgotten, that the acne rosacea 
sometimes appears in people of the most sober 
and temperate habits, and that it sometimes shows 
itself in conjunction with a state of exhaustion 
and general debility. 

In people predisposed to this complaint, either 
hereditarily or by habits of life, it may be imme- 
diately excited by local irritation, as by long ex- 
posure to a hot sun, to the heat of the fire, or the 
application of strong cosmetics. Violent exer- 
cise, bursts of passion, or fits of chagrin, are also 
capable of developing it. Alibert mentions the 
case of a lady, who, having been entirely cured 
of the complaint during a methodical treatment 
of it at the establishment at Tivoli, on receiving 
some afflicting news, in the course of twelve hours 
relapsed into a state worse than ever. But it 
most generally makes its appearance after errors 
of diet, of which, when the predisposition is 
strong, any moderate degree is sufficient to pro- 
duce it. These exciting causes explain why it is 
so generally met with amongst cooks, glassblow- 
ers, mowers, couriers, and players. 

This complaint is, frequently, a symptom pre- 
cursive of diseases of the liver, but sometimes 
they coexist contemporaneously. It seems gen- 
erally to depend more upon a state of abdominal 
plethora, or congestion of the liver, than upon 
any irritation or irritable state of the mucous sur 
faces of the alimentary canal ; and hence spongy 
bleeding gums, and habitually torpid and con- 
fined bowels, are its usual attendants. 

The treatment of acne rosacea demands great 
perseverance, and even in spite of this, it is fre- 
quently unsuccessful. To every form and variety 
of this complaint, with few exceptions, one part 
of the treatment is generally applicable and essen- 
tial, and it is that which consists in a strict ad- 
herence to proper diet and regimen, adapting them 
as much as possible to the correction of that state 
of body which constitutes the predisposition, and 
avoiding all those causes which have the power 
of exciting it. These views will be attained by 
leading a sober temperate life, by using a mild 
diet of easy digestion, by avoiding excesses at 
table, by T abstaining from spirits, liquors, and 
sometimes even wine ; by avoiding hot fires, heat- 
ed apartments, and violent exercises, and by en- 
deavouring to eschew violent emotions of mind or 
close applications of the understanding. The 
power of this plan will be increased, and the 
general object promoted by the use of appropriate 
remedies, suitably adapted to the peculiarities of 
the case. If much local inflammation be present 
with general plethora, a moderate venesection 
may render great service. If the eruption is con- 
nected with the suppression of any accustomed 
evacuation, the propriety of endeavouring to re- 
store it naturally suggests itself; if the menstrual 
function is laborious, imperfect, or irregular the 
proper modification of the method of cure readily 
occurs ; if a congestive state of the liver is pre- 
sent, or when the liver is more severely affected 
mild alterative remedies — as Plumrner's pill! 



ACNE. 



53 



taraxacum, and sulphurous mineral waters, as 
those of Harrogate, are applicable. These last 
are of known efficacy, and are much to be pre- 
ferred to the saline mineral waters. In all cases 
an open state of the bowels is of importance, but 
much purging is generally detrimental. We have 
great doubt whether any constitutional remedy 
has a specific action upon the local disease. In 
France and Germany the dulcamara and viola 
tricolor have been much used ; but we think that, 
united with the general treatment, more benefit is 
derived from the use of the liquor potassa? taken 
a few hours after each meal. 

A judiciously directed topical treatment is of 
^reat importance in the cure of this disease. In 
sudden and acute attacks a few leeches may be 
idvantageously applied near the seat of the com- 
plaint, especially when this eruption affects fe- 
males at the critical period of life, although, in 
these cases, small general blood-lettings are some- 
times of greater service. In the same state, mild, 
tepid, demulcent applications are to be frequently 
used ; amongst these the decoction of beans has 
always enjoyed a great reputation : and as the in- 
flammatory affection subsides, sulphuretted lotions 
form the most useful applications. If the disease 
is not benefited by these means, more stimulating 
lotions may be had recourse to, but in general they 
are less useful in this species of acne, and require 
more circumspection, for they not unfrequently 
aggravate the complaint. Gentle astringent lotions 
of alum, combined with a very small quantity of 
alcohol, are sometimes very useful, and in an in- 
dolent state of the local disease, the vapour-douche 
directed to the part affected, has been often found 
of great service ; the same state also sometimes 
admits of moderate friction, or resolving applica- 
tions. It is to these cases that the remedy of Am- 
brose Pare, a blister applied to the diseased part, 
deserves consideration, a practice the utility of 
which has been occasionally verified in the Hos- 
pital of St. Louis. Nor are the general principles 
of surgical treatment to be neglected here ; for 
when the vari are seated in the follicles, the focus 
of irritation is removed by evacuating them. 

Besides these general and local means of treat- 
ment, the nitro-muriatic foot-bath, in the propor- 
tion of two ounces of the acid to twelve pints of 
water, has been very much recommended ; and in 
many diseases of the skin we have found the 
greatest benefit from sponging the sound parts of 
the skin, two or three times every morning, with 
a lotion consisting of two drachms of nitro-muri- 
atic acid, and two pints of water. It is also fre- 
quently of advantage to apply a blister to the arm, 
or to open an issue as a derivative. 

5. ACXE SYPHILITICA. 

Syn. Gutta rosacea syphilitica (Plenck) ; Sy- 
philide pustuleuse miliare (Alibert) ; Pustules 
syphilitiques psydracees (Rayer.) 

The multifarious forms of cutaneous diseases 
which have been described as originating in syphi- 
lis, may fairly be said to have deprived that dis- 
ease of any specific character, for there is scarcely 
a morbid appearance presented by the skin which 
may not, in a modified state, be found amongst 
syphilitic eruptions. But if any one will take the 
pains to examine into this matter, he will find, 
what might reasonably have been expected as be- 
ing more in accordance with the general laws of 



pathological phenomena, that though there are 
certain forms of cutaneous disease essential and 
peculiar to syphilis, the greater number of those 
described as syphilitic, depend upon the constitu- 
tional predisposition of the individual, modified 
by the syphilitic virus ; and that whilst the influ- 
ence of this disease impresses upon them a gen? 
ral character, their particular form depends upon 
the pathological peculiarity of the individual. 
Thus, if lichen, lepra, or any other cutaneous dis- 
ease, makes its appearance in persons tainted with 
the venereal poison, these diseases, though origi- 
nating in ordinary causes, will suffer a relative 
modification. In proof of this, we find that the 
syphilitic acknowledges the same causes as the 
other eruptions, being excited by errors of diet, 
violent exercise, strong mental emotions, &c. It 
seems, therefore, more natural in a classification 
founded on external characters, to distribute the 
syphilitic eruptions in each genera as their exter- 
nal appearance would require them to be arranged, 
rather than to confound them together under a class 
of anomalous eruptions. In this way the general 
treatment required for this disease may be modi- 
fied by the peculiar character of each eruption, 
and the student will be led more naturally to find 
the place of the eruption in the classification. 
This is evidently the view which Plenck took of 
these diseases, and the plan which Willan intend- 
ed to pursue ; but M. Alibert, as faulty in method 
as correct in description, has formed the venereal 
eruptions into a class under the name of syphi- 
lides, and M. Biett, to whom we are so much 
indebted for a more correct knowledge of many 
of these diseases, has omitted to correct this error 
of classification. They who are conversant with 
diseases of the skin, will find some difficulty in 
following Mr. Carmichael in arranging these erup- 
tions under his papular, pustular, phagedenic, and 
scaly diseases, and will be disposed to doubt whe- 
ther, under these descriptions, he has been so suc- 
cessful as to include such as are peculiar to, or 
characteristic of, the venereal disease. 

Under the term gutta rosacea syphilitica, Plenck 
had marked the acne syphilitica. It corresponds 
nearly to the disease described by Alibert, under 
the term syphilide pustuleuse miliare, and, by 
Biett and Rayer, pustules syphilitiques psydracees. 
It is the least common of the syphilitic pustular 
eruptions, and affects chiefly the face, forehead, 
neck, and trunk. The pustules of this eruption 
correspond very neary in form and dimensions to 
those of acne rosacea; they are round, conical, 
and acuminated, surrounded with an inflamed 
areola, and possess the true character of vari, sup- 
purating only at their apex, and invariably termi- 
nating in tubercles. They are, however, distin- 
guished from them by their deep, red, amaranthine, 
or copper-coloured areola, by their brownish yel- 
low scab, and by their leaving a small, slightly 
depressed cicatrix. A correct delineation of acne 
syphilitica is still a desideratum in this branch of 
medicine ; but, in general, the nose, cheeks, and 
forehead present a livid copper colour, as if stain- 
ed with the lees of wine. In these discoloured 
patches, pustules appear from time to time, which 
leave behind them small dark red tubercles, chiefly 
on the forehead, nose, or adjacent parts of the 
cheeks. As the pustules succeed each other, they 
are to be seen mixed together in every stage of 
their process. With the acne syphilitica may 



54 



sometimes co-exist eruptions of another character 
(frequently scaly) upon the extremities. 

The acne syphilitica is always a secondary sy- 
philitic affection, consequent to chancre ; it is not 
uncommon to see it totally unaccompanied with 
any of the other secondary symptoms of that dis- 
ease, hut its most usual attendants are nodes, 
inflammation of the periosteum, and nocturnal 
pains. 

The specific treatment of acne syphilitica, which 
must still be that on which every prudent practi- 
tioner will chiefly rely, demands modifications 
adapted to the general nature of acne. In the 
early state of the eruption it is better to pursue 
the means found useful in the ordinary forms of 
that disease, and to reserve the mercurial treat- 
ment for the chronic stage. By this method a 
much smaller quantity of mercury suffices for the 
cure. The action of the mercury is rendered 
much more efficacious when combined with a 
course of taraxacum or sarsaparilla. In a case of 
this disease, which came under our care lately, the 
greatest improvement was effected in the eruption 
by the use of sai*saparilla alone, given in powder ; 
in general it is more efficient when combined with 
mercury, and we are acquainted with no prepara- 
tion which fulfils this intention better than the 
celebrated decoction or tisan of Feltz. (R. Aquse 
Oxii : Antimonii sulphurct. §iv : Rod. sarsa- 
parillse ^ii : Hydrargyr. chlorid. corrosiv. gr. iij . 
Ichthyocollse ,§iss. The antimony to be enclosed 
in a muslin bag, and the ivhole to be boiled gen- 
tly until the water is reduced one half, except the 
corrosive sublimate, which is to be added after 
the decoction has been strained, — Oiss is the pro- 
per daily dose.) 

As a local application the fumigation of cinna- 
bar is the most efficacious, lotions being of little 
avail. From one to three drachms of the red sul- 
phuret of mercury may be sublimed and directed 
upon the part by a suitable apparatus. Where 
indurations remain after the specific treatment, an 
ointment formed of the ioduret of mercury (R. 
Rydrargyri iodid. rubr. gr. xi. Adipis §i.) rub- 
bed upon the part, is a remedy of great efficacy, 
and is much assisted by the occasional use of a 
douche of vapour continued for twelve or fifteen 

minutes - T. J. Todd. 

[ACRODYNIA. Erythema acrodynia, E. 
acrodynum; from axpos, extremity, and o&vw, pain. 
A name given to an epidemic neurosis, which pre- 
vailed at Paris, and the neighbourhood, during the 
years 1828 and 1829, and in which the most con- 
stant and remarkable symptoms were numbness, 
formication, and, at times, darting pains in the 
hands and feet. The pain was compared by the 
patients to that which would be occasioned by 
needles or pins run into the parts. It was aug- 
mented by pressure ; was intense for a time; then 
diminished, and after a time disappeared, leaving 
the skin devoid of its natural feeling, and red — 
the cuticle separating in large flakes. Occasion- 
ally, the mucous membranes of the intestinal canal 
sympathized, as indicated by diarrhoea, vomiting, 
gastrodynia, &c. The only constant symptom, 
however, was the pain in the hands and feet. 

The disease was a precursor of the cholera, and 
not less inexplicable in its character and causation. 
Some died of it. It spread chiefly amongst the 
poorer classes, and where numbers of persons 



A C R D Y IN' I A — A C U P U N C T U R E . 

~ere crowded together. In the Caserne des Our- 



Sin Paris, it^ttacked 560 of 700 inmates, 

and in that of La Courlille, in four days, 200 out 
of 500. No one died of it. 

Various remedial a 3 ents were employed ; but 
they appeared to be of little efficacy. I he phe- 
nomena were met by what appeared to be the 
most proper agents; and in the latter periods 
of the epidemic, the therapeutist confined him- 
self to the use of the warm bath, fomentations, 
frictions, and emollient and narcotic cataplasms. 
(Dance, in Art. Acrodynie, in Diction, de Mf.de- 
cine, i. 515, Paris, 1832.) 

About the same period, the Dengue (q. v.) ap- 
peared in the Southern part of this country and 
the West Indies. It seems to have been a con- 
generous affection. The same may be said of the 
affections which have occasionally been described 
under the name Kriebelkrankheiten by the Ger- 
mans. 

The writer had recently under his care a case 
of sporadic Erythema acrodynum, which yielded 
to pencilling the hands and feet with the tincture 
of iodine, after a variety of remedies had been 
used in vain. RoBLEY DuNGLISON.] 

ACUPUNCTURE. The passing a needle 

into the body is termed acuptincture. From for- 
getting that the word puncture has two significa- 
tions, — that it is used to signify both the wound 
and the act of making it, some have termed the 
operation acupuncfuration. But to subjoin the 
syllables ation to the word puncture or acupunc- 
ture, is as improper as to subjoin them to the 
words preparation or fabrication, each of which 
already ends in ation and has a similar twofold 
meaning. An exactly parallel error would be to 
say manufacturation. 

The most obvious purpose of this operation is 
to allow the escape of the fluid of cedema or ana- 
sarca through the skin, or of the blood when su- 
perficially accumulated ; but, from an idea that 
various disorders arose from a kind of subtle and 
acrid vapour pent up, it was had recourse to, for 
the purpose of giving this vent, by the Chinese, 
from time immemorial. From China the practice 
spread to Corea and Japan, where it has for ages 
been very common. 

Ten Rhyne, (Dissert, de Arthritide, de Acu- 
punctura, &c, London, 1693,) a medical officer 
in the East India Company's service in 1679, 
gave the first information to Europe of a practice 
unknown to the Greeks, Romans, or Arabians ; 
and states that a guard of the Emperor of Japan, 
appointed to conduct the English to the palace, 
was seized with violent pain of the abdomen and 
vomiting, after drinking a quantity of iced water 
when heated. He took wine aftd ginger in vain ; 
and then, persuaded that he had wind, had re- 
course to acupuncture in the presence of Ten 
Rhyne. It appears that the Japanese are liable 
to a violent kind of colic called senki, which they 
regard as too severe to arise from morbid matter 
in the cavity of the intestines, and ascribe to some- 
thing morbid in the parictes of the abdomen, the 
omentum, mesentery, and substance of the intes- 
tines, converted by its stay in these parts into a 
vapour, the escape of which from its narrow pri- 
son, by means of acupuncture, i s immediately 
followed by a cessation of the pain and distension. 
The guard laid himself upon his back, placed the 



ACUPUNCTURE. 



55 



point of a needle upon his abdomen, struck its 
head with a hammer once or twice to make it pass 
through the skin, rotated it between his fore-fin- 
ger and thumb till it entered to the depth of an 
inch, and then after thirty respirations, as it would 
appear, withdrew it, and pressed the punctures 
with his fingers to force out the imaginary vapour. 
He made four such punctures and was instantly 
relieved and got well. 

The needles are always made of the purest gold 
or silver, preferably of gold, and well tempered. 
Their manufacture is a distinct occupation, under- 
stood by few, and those few are licensed by the 
emperor. Some are fine, about four inches in 
length, with a spiral handle for the purpose of 
more easily rotating them : and are kept, by means 
of a ring or a piece of silk thread, in grooves, each 
capable of holding one, at either side of a ham- 
mer, usually made of the polished horn of the 
wild ox, ivory, ebony or some other hard wood, 
rather longer than the needle, and having a round- 
ish head covered, on the side which strikes, with 
a piece of leather and rendered heavier by a little 
lead within. Others are of silver only, still finer 
at their point, but with a short thick handle bent 
down upon itself; and are kept, several together, 
in a varnished wooden box lined with cloth : these 
are not struck with a hammer ; but a fine copper 
canula, about an inch shorter than the needle, is 
sometimes employed to steady it, and prevent it 
from entering too far. The selection of the part 
fit for the operation, or for the application of the 
moxa, — the other great remedy of the Japanese, 
is usually confided to particular persons called 
Tensasi, — touchers or searchers of the parts, while 
those who apply the needles are styled Farittute, 
— needle-prickers, though occasionally the com- 
mon people trust to their own experience, taking 
care only to prick no nerve, tendon, nor conside- 
rable blood-vessel. The seat of the cause of the 
symptoms is the proper part, and delineations of 
the body are sold conveying this information. 

If the patient does not bear the needle well, it 
is at once withdrawn : but if he does, and the 
disease proves obstinate, it is introduced two, 
three, four, five, or six times. The more severe 
the affection, and the stouter the patient, the 
deeper must be the puncture. 

Ksempfer,* a physician who accompanied a 
Dutch emhassy to Japan, in 1691, and again in 
1692, informs us that the Japanese make nine 
punctures, three rows of three each, at about half 
an inch from each other, over the liver, in cases 
of colic, and that he himself frequently witnessed 
the instantaneous cessation of the pain, as if by 
enchantment. 

The orientals do not, however, employ this 
operation in affections of the abdomen only. In 
tetanus, convulsions of all kinds, apoplexy, gout, 
rheumatism, swelled testicle and gonorrhoea, and 
in fevers both intermittent and continued, it is 
also celebrated among them ; enjoying credit, like 
all remedies of undoubted efficacy in certain dis- 
ease^ for power which it does not possess over 
otaers. 

Between the frightfulness of running needles 
into the flesh and the high improbability of any 
benefit derived from such a practice, a hundred 

* Envelberhis Kampfer, M. D History of Japan, 
b.inslnfed from the High Dutch by Dr. Scheuchzer. Lon- 
i«n, 1727. 



and seventeen years elapsed before any European 
practitioner made trial of it. Dujardin in his 
Histoire de la Chirurgie, and Vicq-d Azyr in the 
Encyclopedic Methodique, mentioned it above a 
century after Ten Rhyne had published, but only 
to congratulate the world that the statements of 
Ten Rhyne and Kaempfer had not induced any 
one to practise it, and the first European trials 
were made by Dr. Berliozf of Paris in 1810. Its 
power proved so extraordinary that he employed 
it very extensively, and numerous French prac- 
titioners imitated his example with the same 
results. A body of similar English testimony 
followed, and acupuncture affords a striking in- 
stance of a good remedy discovered from ground- 
less hypothesis, and condemned without a single 
trial for above a century. 

The diseases in which the power of acupuncture 
is well established are pain and spasm not de- 
pendent upon inflammation or organic disease. In 
rheumatism of the nerves, rheumatic neuralgia, — 
as distinguished from that chronic form which is 
generally limited to a small extent of nerve, lasts 
a great length of time, and is independent of cold, 
— the invariable causes of rheumatism ; in 
rheumatism of the fleshy parts ; in simple pain 
of any spot ; and in spasmodic and convulsive 
pain of various parts, whether local or migratory, 
its utility is very great, provided inflammation be 
not the cause. Of 129 rheumatic cases treated 
by Dr. Jules Cloquet, about 85 yielded to acu- 
puncture. Of 34 published by others, 28 were 
cured. The writer of this article employed it in 
St. Thomas's Hospital, and published his results 
in the 14th vol. of the Med. Chir. Trans. Of 42 
cases, taken in succession as they stood in the 
hospital-books, 30 were found to have been cured : 
and the remaining 12 had clearly not been adapted 
for the remedy, as either heat of the affected parts 
had existed or heat had aggravated the pain. 
Experience has fully confirmed the fact, that, if 
rheumatism be at all inflammatory, — be accom- 
panied by heat, or aggravated by a high degree 
of heat, even though a moderate degree do not 
aggravate the pain, no relief is in general to be 
expected from acupuncture. The omission of this 
distinction and of a little trouble to make it with 
nicety, will be the chief cause of the operation 
proving unsuccessful in rheumatism. 

In some cases of inflammation and organic 
disease, however, when pain has been felt appa- 
rently disproportionate to those affections, acu- 
puncture is said to have afforded relief. 

The pain both of rheumatism and of some ner- 
vous affections has occasionally shifted its seat on 
the application of the needles, and yielded to their 
repetition in its new situation. Sometimes it 
required longer chasing from part to part before it 
vanished. 

The cures of ophthalmia, blindness, asthma, 
diplopia, and hooping cough, by this remedy, must 
be regarded as lucky occurrences. 

The needles employed in Europe are of steel ; 
long and fine; and furnished with either a knob 
of sealing-wax at their head, or, what is more 
convenient, a little handle of ivory or wood, 
screwing into a sheath for the needle. [They are 
usually from two to four inches lt/»g, the length 
being adapted to the depth it may be desired to 

t Berlioz. Meraoires sur les Maladies Chroniqucs, les 
Evacuations sanguines, et 1' Acupuncture. Paris, lt'lfi. 



50 



A C U P U X C T U K E . 



make them penetrate. If steel needles be selected, 
.hey should be heated to redness and allowed to cool 
slowly, in order that they may be less brittle. At 
the blunt extremity of the needle a head of lead 
or sealing-wax is attached to prevent it from being 
forced entirely into the body. This is the simplest 
method of acupuncture, and it is as effectual as 
any other. If a needle-holder, or porte-aiguille, 
be used, that recommended by Professor F. Bache 
is as good as any that has been invented. The 
needle with its porte-aiguille consists of a handle, 
with a steel socket, to receive the end of the 
needle, which may be fixed securely after having 
been inserted by the pressure of a small lateral 
screw. By this contrivance the operator can at 
pleasure fix in the handle a needle of the length 
he may desire, and, after inserting it, he is enabled 
to detach the handle by releasing the screw. After 
all, however, needles prepared in the simple man- 
ner mentioned above are adequate to every useful 
purpose.] They are best introduced by a slight 
pressure, and a semi-rotatory motion, between the 
thumb and fore-finger; and withdrawn with the 
same motion. The pain is next to nothing, and 
often absolutely nothing. 

The operation may be performed in muscular, 
aponeurotic, and tendinous regions ; and the 
needle introduced to the depth of from i of an 
inch to 2 inches, according to the thickness of the 
muscles. We should not advise it to be passed 
into viscera, articulations, or blood-vessels. In 
general no fluid escapes when the needle is 
removed ; but now and then a small drop of blood 
follows ; and once when the needle had been 
introduced into the pectoral muscle, I knew blood 
to spirt forth, but it was immediately restrained by 
gentle pressure, — an occurrence in every respect 
similar to what once happened in the practice of 
M. Bretonneau.* 

The period during which the needle remains in 
the part is a matter of great importance. The 
pain may indeed cease instantaneously : but more 
frequently does not till the needle has remained 
some time : and my own experience accords with 
that of others, — that one needle, remaining an 



* M. Bretonneau says, that lie had passed needles into 
the cerebrum, cerebellum, heart, liiiurs, and stomach, of 
sucking puppies, through and through, and in all direc- 
tions, with no sign of pain nor particular ill effect; un- 
less when too large a needle was thrust into the heart, 
and in one instance of this, a little extravasation took 
place into the pericardium. So far from fearing to acu- 
puncture the heart. Dr. C'arraco would have us do so in 
the worst cases of asphyxia. He declares that, in the 
presence of several persons, he kept several kittens under 
cold water till they were apparently dead,— stiff, motion- 
less, frothing at ihe mouth, without pulsation of the 
heart, — and regularly sunk to the bottom every time 
ihey were thrown into the water again ; that he passed 
a needle into the heart ; that soon the needle began to be 
gently agitated, then rapidly so, and one voluntary mo- 
tion after another gradually recommenced, till life was 
fully re-established; and that the animals did as well 
afterwards as if nothing had happened. 

Death, however, by acupuncture of the brain or spinal 
marrow, as a secret mode of infanticide, is notorious in 
works on State-Medicine. "Guy Patin relates that a 
midwife was executed at Paris who hud murdered seve- 
ral infants, at the moment their head presented at the 
os uteri, by passing a long and very fine needle into the 
brain through the temples, the foiuanelle, or the nape of 
the neck, or into the heart and its large vessels. Albert! 
and Brendel quote similar examples. In the Causes 
Celebres we read the horrible story of a woman who, 
towards the middle ofthe last century, made it her busi- 
ness to murder all t ho new-born infants that fell into her 
hands by acupuncture, practised at the beginning of the 
vertebral column, or in the brain, with the sole intention, 

ihe told the judges, of peopling heaven more and more.'' 

v oderc, 'I'raitt de .Ve'dceme Legale, t. iv. p. 492. sq. 



hour or more, is far more efficacious than several 
speedily withdrawn. I usually allow them to 
remain one or two hours j and have known them 
reman, twenty-four hours, without any ill eliect. 
I have usually found the operation requisite a 
second time, and in one case, lumbago did not 
yield till the ninth repetition. 

The modus operandi of acupuncture is un- 
known. It is neither fear nor confidence ; since 
those who care nothing about being acupunctured, 
and those who laugh at their medical attendant 
for proposing such a remedy, derive the same 
benefit, if their case is suitable, as those who are 
alarmed and those who submit to it with faith. 
Neither is it counter-irritation ; since the same 
benefit is experienced when not the least pain is 
occasioned, as when pain is felt. Galvanism, 
likewise, fails to explain it ; because, although the 
needle frequently becomes oxidated and affords 
galvanic phenomena while in the body, these 
phenomena bear no proportion to the benefit, 
equally take place when acupuncture is practised 
upon a healthy person, and do not take place 
when needles of gold or silver are employed, 
which, however, are equally efficacious with a 
needle of steel. 

[We can scarcely conceive the effects to be 
anything more than a new nervous impression 
produced by the needle in the parts which it 
penetrates.] 

Acupuncture has been successfully employed 
to remove the fluid of oedema and anasarca. In 
these cases, the needle does not require to be 
passed deeply; its point has merely to go through 
the cutis. As soon as this is done and the needle 
withdrawn, a small bead of water appears at the 
puncture, which augments till the fluid runs 
down ; and the oozing will continue for a longer 
or a shorter time, — generally for some hours, 
occasionally for a few days, and even after death, 
should that event take place. Any number of 
punctures may be made. Although the puncture 
is so minute, it is, in such cases, not devoid of 
danger, any more than scarification, if practised 
below the knee. The writer has frequently had 
recourse to it with great advantage in oedema of 
the scrotum and penis, frequently along the trunk, 
and the whole length of the superior extremity, 
and on the posterior part of the thigh, and never 
saw or heard of the least inconvenience. But 
several cases have been related to him, in which 
sloughing, and in some of which fatal sloughing, 
resulted from its performance below the knee, 
even though the needle had been passed merely 
through the cutis. Before these cases came to his 
knowledge, he had acupunctured the leg, and even 
the foot, in dropsy, and never but once saw any 
inconvenience, and that was merely a suppuration 
at each puncture. It should evidently, however, 
never be performed below the knee except when 
absolutely necessary, a circumstance that hardly 
can happen, except in oedema not extending 
higher than the knee : and when we reflect that 
acupuncture removes an effect only, leaving the 
cause of the effusion untouched, and that a lar^e 
number of effusions are the result of an inflamma- 
tory state, or of sanguineous congestion, and that, 
while lessening or removing these by bleedin^ 
general or local, or purging, we are employing 
means which have also a direct tendency to ex- 
cite absorption; and when we reflect upon th« 



AGE 



57 



powers of diuretics when those measures have 
previously been properly employed, we shall per- 
ceive that the cases of dropsical effusion in which 
acupuncture is required, are comparatively few. 

[Dr. Dunglison has used acupuncture with ad- 
vantage to drain off the fluid from the cellular mem- 
brane in anasarca. In such cases, larger needles 
are advisable. Some prefer them to be of the size 
of an ordinary glover's needle, and of a triangular 
shape, — a puncture of this kind being less likely 
to close. It has likewise been advised in ascites, 
in hydrocele, and in every form ol encysted dropsy. 
By M. Velpeau it has been proposed to treat aneu- 
rism by acupuncture. In performing some experi- 
ments on animals, he found that arteries, punc- 
tured by the needle, became the seat of a coagulum, 
and were ultimately obliterated. In 1830, he read 
a paper before the Academie Royale des Sciences 
of Paris, proposing the operation in the cases in 
question, \Lond. Med. Gaz., and Amer. Journal 
of the Medical Sciences, Aug. 1831, p. 510). He 
found, in his experiments, that whenever the 
needle remained three days in the flesh, the trans- 
fixed artery was completely obliterated. 

M. Bonnet treated eleven cases of varicose veins 
by introducing pins through their cavities, and 
allowing them to remain there some time. Nine 
of these cases were cured. The same treatment 
was applied to hernial sacs. He passed three or 
four pins through the hernial envelopes close to 
the inguinal ring, and, in order that they might 
exert a certain degree of compression, as well as 
irritation, on the sac, he twisted the points and 
heads upwards, so as to give them a circular direc- 
tion. The inflammation usually commenced on 
the third or fourth day, and the pins were removed 
a few days afterwards. M. Bonnet treated four 
cases of inguinal hernia in this manner. In two, 
the hernia was small, and three weeks sufficed for 
the cure : the third was more troublesome. (Bul- 
let. General de Therap., and Amer. Med. Intelli- 
gencer, Dec. 1, 1837, p. 317 ; and Archiv. Gene- 
ral, de Midecine, Mai, 1839.) 

Acupuncture has likewise been employed to 
remove a ganglion of considerable size on the 
extensor tendons of the foot. After the needle 
was inserted, pressure was applied, and within a 
week the tumour had entirely disappeared. (Mr. 
Vowell, Load. Lancet, Aug. 25, 1838, p. 770.) 
When acupuncturation is conjoined with galva- 
nism or electricity, it constitutes galvano-punc- 
ture and electro-puncture (q. v.). See, on the 
whole subject of acupuncture, Dunglison's New 
Remedies, 4th edit., p. 53. Philad. 1843.] 

John Elliotson. 

AFFUSION. See articles Bathi>g and 
Fever. 

AGE. In nothing are organized beings more 
remarkable than in that perpetual mutation which 
seems to constitute the fundamental law of their 
condition. The whole period of their existence is 
characterised by a series of actions and reactions, 
ever varying, and yet constantly tending to defi- 
nite ends. The parts of which they consist undergo 
continued and progressive changes in their size, 
form, arrangement, and composition. The mate- 
rials which have been united together, and fashioned 
into the several organs, are themselves severally 
and successively removed and replaced by others, 
which are again in their turn discarded, and new 
ones substituted : till, in process of time, scarcely 

Vol. I. — 8 



any portion of the substance originally consti- 
tuting these organs, remains as a component part 
of their structure. 

This continued renovation of the materials of 
which the body consists, takes place in the most 
solid as well as in the softest textures ; and so 
great is the total amount of these changes, that 
doubts may very reasonably be entertained as to 
the identity of any part of the body at different 
epochs of its existence. A period of seven or 
eight years was assigned by the ancients as the 
time required for this entire change of all the 
materials of the system ; but modern researches, 
which show us the speedy reparation of injured 
parts, and the rapid renewal of the substance of 
bones that have been tinged by madder given to 
animals with their food, render it extremely pro- 
bable that a complete renovation may actually 
take place in a much shorter period. 

General as this law may appear, it is subordi- 
nate to another and more universally controlling 
principle, to which all beings endowed with life 
are subjected, namely, the Law of Mortality. 
Every living being has a period assigned for its 
existence. With the germs of life are intermixed 
the seeds of death ; and, however vigorous the 
growth of the fabric, however energetic the en- 
dowments of its maturity, we know that its days 
are numbered ; and that even if it should escape 
destruction from causes that are accidental and 
extraneous, it is sooner or later doomed to perish 
by the slow, but unerring operation of natural 
and internal causes, inseparable from its. nature, 
and coeval with its birth. 

In tracing the gradual succession of phenomena 
that mark these eventful changes, and constitute 
the numerous and almost insensible steps of tran- 
sition which connect them, a multitude of inter- 
esting topics of inquiry present themselves. Much 
instruction is afforded with regard to the physical 
laws of the animal economy, by the study of that 
condition in particular of the system, in which it 
has passed its meridian state of activity, and may 
be regarded as on the decline ; and in which the 
causes that ultimately conduce to its destruction 
begin to prevail over the conservative powers that 
had hitherto predominated. Such is the state 
which is emphatically denominated Age. 

As youth is the state of transition from infancy 
to maturity, so age is the state of transition from 
maturity to decay. In the early periods of life, 
all the powers of the system are directed to the 
building up of the frame, and of the different 
organs ; to their extension, consolidation, and 
perfection ; and to their adaptation to the perfor 
mance of their several functions. The exertiom. 
made for the attainment of these objects are great, 
and commensurate with the magnitude and im- 
portance of the design ; and they give rise to a 
rapid and varied succession of changes. An 
abundant store of materials is wanted for these 
operations ; and although the consumption and 
renovation of these materials be considerable, yet 
the supply much exceeds the loss ; and the body, 
accordingly, continues to augment in bulk, [n 
course of time, these opposite processes of reputa- 
tion and decay approach nearer to an equality, 
and, at length, are exactly balanced. The parts 
then cease to grow ; the system has reached its 
state of maturity ; and the object of the vital 
powers and functions is now to maintain it in o 



59 



A G E . 



uniform condition of health and vigour, qualified 
for the exercise of all its physical and mental 
faculties. It cannot but excite our admiration to 
contemplate the accuracy of the adjustments by 
which these objects arc so perfectly accomplished, 
and that equilibrium preserved, with such won- 
derful constancy, for so long- a period of years. 

But at length there comes a season when the 
balance, hitherto so evenly kept, begins to incline ; 
the powers of the. system are less equal to the 
demands made upon them ; a diminution of 
energy becomes sensible ; and the waste of the 
body exceeds the supply. Yet nature is far from 
abandoning her work : new arrangements are 
made, and new provisions resorted to for accom- 
modating the system to these changes. In pro- 
portion as the supply of materials for repairing 
the waste of the organs becomes less abundant, 
a more strict economy is adopted ; the resources 
of the system are husbanded with greater care ; 
and the functions thus appear to go on for a con- 
siderable period without any material or very 
manifest alteration. Yet all this time the changes 
which are going on, though insidious, are no less 
real. Old age steals upon us by slow and imper- 
ceptible degrees, which, even when obvious to 
others, are often unknown to ourselves. Nature, 
when the system is entrusted wholly to her laws, 
thus kindly smooths the path along which we 
descend the vale of life, and conducts us by easy 
stages to our destined place of repose. But the 
number of those who thus gently glide along the 
stream of years is small indeed, compared with 
those whose declining age is withered by infirmi- 
ties or embittered by disease. The " Age that 
melts in unperceived decay" is rarely met with 
amidst the numerous and diversified causes of 
premature decrepitude, to which man, in his 
civilized condition, is obnoxious. 

Various and complicated as are the changes 
which the system undergoes in passing from the 
state of maturity to that of old age, and thence 
to decrepitude and dissolution ; and, different as 
are the objects which nature appears to have in 
view in the several periods of life, it is probable 
that a minute inquiry into all the circumstances 
that mark these epochs, will reveal to us the con- 
tinued and uniform operation of the same prin- 
ciples throughout the whole succession of these 
changes. The experience we possess of the 
plans and operations of Nature in other instances 
is altogether in favour of such a hypothesis. But 
in order to form a proper estimate of the degree 
of confidence to which it is entitled, we must 
examine the exact nature of the progressive 
changes which have been observed to take place 
by age in the several classes of textures and func- 
tions composing the animal economy. 

In this inquiry our first attention will naturally 
be directed to the mechanical properties of the 
several textures. The most superficial view of 
the subject will suffice to impress us with the 
great difference that exists in the relative propor- 
tion of fluids and solids in the earlier and in the 
later periods of life. The primitive condition of 
the embryo is, in all animals, that of a gelatinous 
pulp. In this pulp we trace, by degrees, the form- 
ation of filaments and membranes : these extend 
and are fashioned into organs of various kinds, 
which long retain their original softness of con- 
ustence and imperfect cohesion. The accretion 



Of new materials imparts to them, in process of 
time (rreater density and firmness. The propor- 
tion 'of solid matter that enters into their com 
position thus continually augments ; the body 
exoands in all directions, and soon requires some 
mechanical basis of support. This support is 
provided in the osseous structures that arc now 
superadded ; at first only partially, and in de- 
tached masses ; but these are afterwards united 
into a connected framework of bone, which con- 
tinues to receive developement during the whole 
period of the growth of the body. The softer 
textures are at the same time gradually consoli- 
dated, and acquire a higher degree of elasticity : 
while they, in the same proportion, become less 
flexible and less extensile. All the parts that are 
principally formed out of the cellular tissue ex- 
hibit these changes most remarkably. They are 
very perceptible in the membranes, ligaments, 
tendons, and cartilages ; and they may be traced 
even in the muscles themselves. The condensa- 
tion of all these parts proceeds as age advances, 
and is then attended with a general contraction 
of their dimensions. All the parts composed of 
fibres acquire toughness by age. This is matter 
of common observation with regard to animals 
that are used as food ; the flesh of old animals is 
less easily torn asunder by the teeth, and is less 
digestible by the stomach, than that of the same 
species when young. In very old animals, parts 
that had originally been muscular, appear, by a 
change of substance, to be converted into tendons; 
a denser material being substituted for the proper 
muscular fibre. 

The deposition of a bony material in various 
structures to the purposes of which it is quite 
foreign, and where, consequently, it appears to be 
misplaced, is an extreme instance of the same 
tendency to increased density of texture. Ossi- 
fication takes place, in advanced age, in various 
membranes, in the coats of the blood-vessels, in 
the coverings of the viscera, and more especially 
in tendons and cartilages. A similar change 
affects even the bones themselves ; for they be- 
come harder and more brittle in the progress of 
age. The tendency to ossification, arising from 
the redundance of osseous matter, is occasionally 
so great as to lead to the formation of osseous 
tumours in various parts of the body. In this 
respect, therefore, the bones differ from almost all 
the other parts of the body ; for while the latter 
shrink and contract in their dimensions by age, 
the bones, on the contrary, have a tendency rather 
to augment in size, or at least to increase in the 
quantity of solid materials which compose them. 
Those bones, which, in the adult, are detached, 
are frequently united in advanced life : such as 
those of the sternum and of the skull, the sutures 
of which are commonly obliterated, first on the 
inner, and lastly on the outer surface : so that, at 
length, almost the whole cranium consists of a 
single bone. 

But even when not converted into bone, the 
fibrous structures lose their flexibility by age, and 
acquire a degree of rigidity which often disquali- 
fies them for the performance of their jsual func- 
tions. The joints of old persons become leal 
pliable from changes of this kind taking place in 
the synovial membranes and the surrounding liga- 
ments. The intervertebral cartilages und. 
age, a similar process, which impairs considerably 



AGE. 



59 



the flexibility of the spinal column, and contri- 
butes to the bending forwards of the body and to 
its diminished stature. It has been observed of 
the fibrous tissues of old persons, that they assume 
a deep yellow colour, indicating the condensation 
of their substance, and resembling what takes 
place when they are artificially dried. 

From a consideration of these and other cir- 
cumstances, the general fact may be considered 
as established, that the proportion of fluids in 
each organ, and also in the body generally, 
diminishes as we advance in life. This remark 
applies more especially to the general mass of the 
blood ; but it holds good also with regard to all 
the other fluids : and we can scarcely doubt that 
a considerable proportion of those peculiarities 
that characterise the period of senility may be 
traced to the long continued operation of this 
principle. 

Together with the mechanical changes of tex- 
ture we have now described, we find that there 
also take place considerable alterations in the 
chemical condition of the fluids, and solids of the 
body. In the foetus and the infant there exists a 
large proportion of water and of gelatin : phos- 
phate of lime is but little abundant, and fibrine is 
but scantily developed. These two latter elements 
increase in quantity as the growth of the body 
proceeds. On the other hand, as age advances, 
the gelatin gradually disappears, or at least bears 
a much smaller proportion to the other animal 
constituents, namely, the albumen and the fibrin ; 
the aqueous portion is much diminished in quan- 
tity, and the phosphate of lime, as before remark- 
ed, often accumulates in an excessive degree. 
Not only is the quantity of gelatin diminished, 
but it appears to undergo an alteration in its 
quality by the effects of age. Glue obtained from 
young animals is found to differ essentially from 
that which can be procured from old animals. 
Calves'-feet jelly is not the same with the jelly 
afforded by the feet of the full-grown ox. The 
latter has a deeper colour, is less digestible, and 
passes more slowly into a state of putrefaction. 
A similar remark applies also to the fibrous tex- 
tures themselves, which become yellow by age, 
are less easily resolved by maceration, and resist 
putrefaction for a much longer time than the same 
parts taken from young animals. 

If we next examine the changes which the se- 
cretions undergo, we shall find that they partake 
of the general diminution of fluidity incident to 
old age. Those that consist chiefly of the watery 
exhalations of the blood are more scanty than in 
early life. The perspiration, for instance, is far 
less abundant. A deficiency of lymph is percep- 
tible in the cellular tissue; and the lymphatic 
vessels, having less fluid to convey, shrink in 
their diameter : and a large proportion of them, 
becoming useless, are obliterated and lost. The 
same takes place with regard to the lymphatic, 
glands, which, from being large and turgid in 
infancy, are smaller and more compact in the 
adult, and either become ossified or entirely dis- 
appear in old age. The blood itself becomes 
darker coloured in advanced life. From the dimi- 
nution of perspiration, less animal matter is ex- 
creted by the skin, arid more is carried off by the 
discharges from the mucous surfaces. We may 
probably ascribe to this cause the fcetor which is 
so often attendant on the breath of old persons. 



From the same cause the urine is generally higher 
coloured, more odorous, and more prone to calcu- 
lous deposition. From the mucous membranes 
of the nose, fauctii, trachea, and lungs, there is 
frequently, indeed, a disposition to more copious 
secretion than exists in a less advanced age ; but 
this ought rather to be regarded as a state of chro- 
nic disease than as the natural condition of the 
parts. When it prevails, however, the mucus 
poured forth is opaque, viscid, and tenacious ; and 
its abundance proves a source of continual dis- 
tress to the aged valetudinarian by the obstruction 
it occasions to free respiration, and by the perpet- 
ual efforts required for its expulsion. 

The integuments, being the parts of the body 
mo«t exposed to observation, exhibit more distinct- 
ly, perhaps, than any other, the changes induced 
by age. It is doubtful whether the cuticle, which 
of all the textures seems to partake the least of 
vitality, and which has even been considered as 
wholly inorganic, suffers any other alteration in 
process of years, than that of becoming somewhat 
thicker and more dry, and more disposed to peel 
off in scales. Compared, indeed, with its struc- 
ture in infancy, when it is very thin and delicate, 
and allows of the ready transmission of impres- 
sions to the subjacent nerves, the cuticle of the 
aged presents a striking contrast; but between the 
aged and the adult the differences, in these re- 
spects, are scarcely perceptible. The principal 
changes that take place during the transition be- 
tween these latter periods are observable in the 
subjacent textures. The corpus mucosum acquires 
by age a darker colour, as well as greater conden- 
sation. The cutis vera, also, exhibits greater den- 
sity and toughness ; while it loses in the same 
proportion its extensibility, and power of accom- 
modation to the size and figure of the parts it co- 
vers. The difference in the texture of the skin 
at different ages is very perceptible to the dissect- 
or ; and both the scalpel which divides the skin, 
and the needle employed to sew it together after 
division, meet with considerably greater resistance 
in old than in young subjects. As it no longer 
adapts itself to the alterations of position or of 
bulk which occur in the subjacent parts, it be- 
comes flaccid and wrinkled whenever these parts 
diminish by age. All this is very perceptible in 
the face, neck, and hands. Hence we may trace 
the gradual shrinking and corrugation of the fea- 
tures, which regularly follow the progress of years, 
and which afford unerring indications of age. 
Witness the dark coloured furrows of the cheeks 
and lower part of the face, the result of reiterated 
impressions from various passions, of which the 
predominating effect is to draw down the corners 
of the mouth, and compress the nostrils : witness 
the lesser lines on the temples, radiating from the 
eves, and denoting the increased efforts which ac- 
company the employment of those organs : wit- 
ness, also, the deeper wrinkles in the brow and 
forehead, bearing the impress of intense and anx 
ious thought. 

(Irey hairs, the proverbial attendant upon age, 
exemplify the operation of the same principle of 
defective nourishment and suppressed secretion 
Early and vigorous in their growth, the hairs of 
the head are generally the first to show symptoms 
of decay. Great differences may, however, be 
observed in different individuals, as to the period 
when the hair exhibits a change of colour, or falls 



CO 



AGE. 



off. In some, it grows grey at thirty years of age, 
or even curlier ; with others, this change does not 
take place till other and less equivocal indications 
of age are manifested. Many causes which aii'cct 
hut little the general constitution, accelerate the 
death of the hair ; and more especially the de- 
pressing passions, intense thought, and corroding 
anxieties. Fevers are often destructive of the 
vitality of the hair, when they do not permanently 
affect any other part of the body. There is, how- 
ever, an essential difference in the effects of dis- 
ease and of old age upon hair, inasmuch as the 
former seldom destroy the bulbous capsule from 
which the hair is formed ; and, accordingly, a 
new crop of hair is often found to spring up, after 
a certain time, when the system recovers its vigour. 
But the death of hair from age is hopeless and 
irretrievable, for it implies the destruction of every 
part of the root, as well as the shaft ; and the 
consequent separation of the hair is attended with 
the obliteration of the canal which it occupied, 
and which penetrated the true skin. 

The loss of colour in hair begins in the shaft, 
which first becomes grey, then white, and lastly 
transparent, giving to it that silvery appearance 
which is esteemed so venerable a mark of age. 
Baldness generally commences over the upper 
parts of the temporal and occipital bones, particu- 
larly in the male sex ; and thence spreads over 
the whole upper surface of the head. The hair 
on other parts of the hody suffers corresponding 
changes with those of the head, and also falls off 
partially by age. 

The alterations which take place in the eyes 
by the progress of age afford another instance of 
the tendency to a diminution in the aqueous con- 
stituents of the body. As the quantity of the aque- 
ous humour in the anterior chamber of the eye 
diminishes, the cornea necessarily becomes less 
prominent, and its curvature being thus diminish- 
ed, it ceases to have the same refractive power. 
The vision of near objects becomes indistinct ; 
because the rays proceeding from them, and arriv- 
ing at the cornea with a sensible degree of diver- 
gence, are not sufficiently refracted to enable them 
to meet in a focus upon the retina : and the im- 
ages there formed are, consequently, confused. 
Such is the condition of the presbyopic eye, re- 
quiring the assistance of a convex lens in order 
to supply this deficient power of convergen e. 

There is, however, great reason to believe that 
the mere change of convexity of the cornea is not 
the sole, nor even the principal cause of the inca- 
pacity of the presbyopic eye to see near objects 
distinctly : for this defect is more connected with 
the diminution in the powers of adjustment in the 
eye, owing to impaired muscular power. 

Changes also take place in the more internal 
parts of the eye by old age ; the crystalline lens 
generally acquires a yellow or amber colour ; and 
its transparency diminishes. The sensibility of 
the iris is impaired; and the pupil is habitually 
more dilated than formerly. The pigmentum 
nigrum has been known to lose its colouring 
material, and to become almost transparent. This, 
as well as the larger aperture of the pupil, have 
been considered as special provisions of nature 
for admitting more light to the retina, in compen- 
sation for the diminished sensibility of the nerves 
of vision. 

It is probable that the various parts of the in- 



ternal car are affected by the progress of ago 

The fluid which occupies the internal cavities is 
said to be gradually absorbed, so that at length >t 
is found to have entirely disappeared. When- 
ever this happens, it must of course be produc- 
tive of irremediable deafness. But many other 
causes, which relate to other branches ot our sub- 
jeet. may contribute to the tendency to deafness 
incident to advanced life. 

Among the causes of the changes that take 
place in the internal organs, the most important 
is the alteration in the condition of the blood- 
vessels. Not only does the proportion which the 
blood-vessels, taken altogether, bear to the whole 
bulk of the body, undergo a gradual and progres- 
sive diminution from infancy to youth, from youth 
to manhood, and from manhood to old age ; but 
a material alteration takes place, during these suc- 
cessive periods, in the relative disposition of the 
several classes of vessels among themselves. 
While the body is extending in growth, the arte- 
ries are exceedingly numerous, and pervade every 
part ; but in proportion as that extension ap- 
proaches to its limit, they contract in their dia- 
meter, being less capable of dilatation in conse- 
quence of the increased density and rigidity of 
their coats. This contraction is chiefly percepti- 
ble in the smaller arteries ; a number of the minu- 
ter vessels become impervious, and gradually dis- 
appear, or assume the form of ligamentous fila- 
ments. The sanguineous appearance which is 
common to so many parts in youth is altogether 
lost. Few red points are seen on separating the 
periosteum from the bones, or the dura mater 
from the cranium, in old subjects ; and scarcely 
any blood issues on making a section of these 
bones. In making anatomical injections, we al- 
ways succeed best with young subjects ; in the 
old, we can often do no more than fill the arterial 
trunks, from the resistance that is opposed to the 
passage of the injection into the lesser branches. 
The coats of the arteries themselves appear desti- 
tute of the vessels which are proper to them, and 
which are so conspicuous at a less advanced age. 

But this obliteration of so large a proportion 
of minute arteries and capillary vessels, gener- 
ally, is accompanied with a greater comparative 
dilatation of the veins. The coats of the veins 
are originally thinner than those of the arteries ; 
and as they do not partake of the changes which 
we have described as taking place in the arteries, 
they come to differ more and more from the latter 
in their texture, as age advances. Instead of 
thickening and contracting, it would appear, in- 
deed, that they became rather thinner and more 
dilatable than before. This perhaps arises from 
the coats of the veins having a smaller proportion 
of cellular substance interposed between them 
than the coats of the arteries ; they, therefore, 
scarcely participate in the increasing condensation 
of that substance, but are more under the influ- 
ence of the action of the absorbents. Certain it 
is that in extreme old age the veins are very full 
and prominent, and their course more tortuous : 
their total capacity must therefore be increased. 
Hence, while the total quantity of blood in the 
body is diminished by age, a greater proportion 
of the whole mass is contained in the venous than 
in the arterial system. In youth this proportion 
was nearly equal ; in age the veins contain, Dei- 
haps, two-thirds of the mass of blood. 



AGE. 



61 



Much light has been thrown on the changes 
that take place in the texture of the different 
classes of blood-vessels by the researches of Sir 
Clifton Wintringham, whose experiments have 
clearly proved the greater proportional density of 
the coats of the arteries to that of the veins in old 
than in young animals. Hence it follows, as a 
necessary consequence, that they must yield more 
easily to the distending forces of the circulation ; 
and hence, whenever a plethoric state of the sys- 
tem occurs, that fulness will, in youth, affect more 
the arteries, and, in age, the veins. It is on these 
principles that Cullen founded his celebrated and 
beautiful theory of hemorrhagy, which gives so 
natural and satisfactory an explanation of the 
prevalence of arterial hemorrhagies in the earlier 
periods of life, and of venous hemorrhagies in the 
later periods. Hence, also, the greater frequency 
of hemorrhoids, and of sanguineous apoplexy in 
the old. 

The veins of the inferior extremities are very 
liable to varices in advanced life ; and they are 
generally more dilated than those of the arms or 
other parts ; for the pressure of the column of 
blood they have to support is a force which con- 
stantly operates to distend them, and which, when 
their strength is diminished by age, they are un- 
able to withstand. This proneness to varix is 
particularly observable in elderly women who 
have borne many children, from the frequent dila- 
tation the veins have experienced in consequence 
of the pressure uf the gravid uterus. It is re- 
marked by Bichat, that, while young subjects are 
preferable for tracing the course of the arteries, 
anatomists should choose old bodies for studying 
that of the veins. 

It appears, also, that the growth of the heart 
does not keep pace with that of the sanguiferous 
system ; and we may presume, therefore, that its 
force does not increase in the same proportion 
with the increasing density and resistance of the 
solids. This gradual alteration in the balance of 
the forces of propulsion and of extension, that 
takes place during the growth of the body, is con- 
tinued in after life, and is one of the primary 
causes of the observed phenomena of age. The 
diminished energy of the heart, in these later 
periods, is manifested by the languor and slow- 
ness of the pulse, which becomes, at the same 
time, apparently more full ; occasionally we find 
it intermittent, indicating the diminished irrita- 
bility which pervades the system, and in which 
the heart at length participates. In old persons 
the number of pulsations in the minute often 
does not exceed fifty, and is sometimes even less 
than this. 

The consequences resulting from the diminish- 
ed energy of the circulation, and the deficiency 
in the circulating fluids, are sufficiently obvious, 
and may be traced in all the functions. Not only 
will less blood be sent to the several organs, but 
the blood that is sent, is, perhaps, less completely 
acted upon by the air in respiration, on account 
of the diminished proportion which is transmitted 
through the pulmonary system of vessels. The 
diminution of secretion, and the deterioration of 
the fluids prepared by the secretory organs, are 
direct consequences of these changes. The func- 
tion of digestion itself, the source of those ma- 
terials from which the blood is prepared and its 
losses replenished, and from which all the parts 



derive their nutriment, is less effective than for- 
merly. On the whole, however, the changes that 
take place in the secretions, and in the powers of 
digestion, are less considerable than those that 
occur in other functions. The liver and kidneys, 
for example, are nearly as active, and perform 
their respective offices as completely in age as in 
maturity, and while the muscular and nervous 
powers have sensibly declined. An exception 
occurs, indeed, with regard to the secretions sub- 
servient to generation, which, together with the 
generative powers, entirely cease after a certain 
period of life, which varies considerably in differ- 
ent individuals. In the male sex, after the func- 
tions of the testes have ceased, an absorption fre- 
quently commences in these glands, which shrink, 
become soft and pulpy, and sometimes almost 
wholly disappear. The prostate gland, and espe- 
cially the posterior lobe, is exceedingly liable to a 
morbid enlargement. In the female, the ovaria 
shrink in size, and lose their vesicular structure. 
The mammae, when not affected by scirrhous in- 
durations, are also softer, less elastic, and fre- 
quently pendulous ; but in advanced age they are 
often totally absorbed, and even the nipple is 
scarcely apparent. The areola generally assumes 
a darker colour, even prior to the period when 
menstruation ceases. 

This increased activity of the absorbent system 
may, on the other hand, be considered as a com 
pensation to the diminished power of the sangui- 
ferous system. The absorbents seem to retain 
their powers for a longer time than the heart and 
arteries ; and their disproportionate action is the 
occasion of many changes, that take place in the 
form and bulk of various parts. It is one prin- 
cipal cause of the general consolidation and in- 
duration of the organs. It is productive of a 
state of comparative emaciation, from the removal 
of the fat, which, in the adult, is interspersed very 
largely in the subcutaneous cellular texture, as 
well as in many other more internal parts. The 
effects of the loss of adipose substance are very 
visible in the countenance ; the eyes retreat into 
the sockets, the cheeks become hollow, the teeth 
decay, loosen, and drop out, the gums and the 
alveoli themselves are reduced by absorption ; all 
combine to alter the features, and transform theii 
expression to that which characterizes age. The 
lower jaw, deprived of its teeth, advances, so that 
the chin projects, and comes nearer to the nose ; 
and the cavity of the mouth being thus diminish- 
ed in its capacity, the tongue often appears too 
large to be contained in it. Amidst this general 
change in the configuration of the bones of the 
face, the nasal cavities remain undiminished in 
their size. 

At a still more advanced period, however, we 
frequently have occasion to observe a failure of 
action in the absorbents, and a consequent ten 
dency to dropsical accumulations. 

80 intimately are all the functions of the ani 
mal economy linked together in one harmonious 
system, that a change made in any one of them 
must necessarily affect all the others, by disturb- 
ing the nice balance which is established by nature 
between them. Hence the difficulty that must 
always be felt in tracing to their origin the long 
and complicated scries of changes that constitute 
any considerable alteration in the state of the 
system : and when, as in the present case, I he in 



G2 



AGE. 



quiry relates to alterations that are extremely 
gradual, and extend over considerable periods of 
time, we are still less likely to arrive at any cer- 
tain conclusion. Thus, afler prosecuting our in- 
duction of facts to the length of establishing cer- 
tain leading principles, according to which the 
slow progress of years affects the different organs 
and functions of the body, we find great difficulty 
in proceeding farther in their generalisation, and 
in reducing them to a single principle. We have 
seen, for example, that a great number of changes 
occurring in the body by the lapse of years imply 
the operation of a general consolidating cause, 
affecting both the solids and fluids, and exerted 
especially on the cellular and membranous tex- 
tures, which appear to be primarily acted upon, 
and through which all the parts into which the 
cellular texture enters as a principal component 
part, become also more and more condensed as 
age advances. The gradual diminution of the 
energy of circulation, and the obliteration of the 
minuter vessels, constitute together another gen- 
eral fact, which includes a large proportion of the 
phenomena characterizing the transitions from the 
earlier to the later stages of life. Now it may be 
proposed as a question whether these two causes, 
while they act conjointly, act also independently 
of one another ; or whether the one is not an 
intimate and necessary consequence of the other. 
Is the closing of the capillary arteries, it may be 
asked, the effect of the tendency which the ani- 
mal fibre has to progressive condensation ; or is 
not this condensation the effect, rather than the 
cause, of the diminished impetus of the circulat- 
ing fluids incident to age ? Again, if we admit 
this last hvpothesis to be the true one, then we 
have still farther to seek for the cause of this dimi- 
nution of force in the circulating fluids : and this 
brings us to another step in the investigation, 
namely, the inquiry into the changes which take 
place, in the progress of life, in the muscular and 
nervous powers. 

The muscles are found to undergo, in the course 
of years, changes as considerable, though perhaps 
not so obvious, as the other textures. They par- 
ticipate in the condensation incident to the cellular 
texture that enters so largely into their composi- 
tion, and which, as has already been pointed out, 
frequently acquire, by the deposition of fibrous or 
even osseous matter, the density of tendon or of 
bone. This excess of density in the cellular mem- 
brane, that invests the muscular fibres, is itself an 
impediment to the free contraction of those fibres, 
which are, therefore, from this cause, performed 
more slowly. But independently of this, a change 
also takes place in the muscular fibres themselves : 
they become more rigid, and the total size of the 
muscle is diminished. Its contractility is also im- 
paired ; so that it is less readily as well as less 
powerfully influenced by stimuli. The muscles 
of voluntary motion are less under the control of 
the will ; and the involuntary muscles execute 
their functions with diminished energy. 

Not only is the irritability of the muscle im- 
paired, but also that property which has been 
•.lenominated its lone is diminished. The texture 
of the muscles of elderly persons is loose, flabby, 
and relaxed : this fjaccidity is perceived more 
especially in the thick muscles of the lower ex- 
tremities, as the glutrni, the solaei, the gastroencmii, 
.in ! biceps muscle* ; while, at the same time, the 



in(livi(lu;ll fibres of those muscles arc, ta tW 
aelvea, tough and dense. A greater degree ot 
;. , : iU tion ^characterizes the actions of the mua- 
Erf the limbs in advanced age Hence the 

tottering and uncertain gait of the mfirm old man. 
Bichat observes that this irregular action of the 
muscles is generally accompanied by a deteriora- 
tion of their substance, indicated by greater pale- 
ness and the assumption of a light yellow colour, 
as if an approach was made to their conversion 
into sebaceous matter. He remarks that tins 
change is more commonly observed to take place 
in the deep-seated muscles of the back, which 
occupy the longitudinal spaces between the pro- 
cesses of the vertebroe ; and that it does not affect 
the muscular system generally, but only a small 
number of isolated muscles. (Bichat. Anatomic 
Generate, torn. iii. p. 336.) The same phenome- 
non has been noticed in muscles that had long 
been affected with paralysis. 

The prevailing diminution of muscular strength 
is manifested, very unequivocally, in the affection 
of the voice, which, in old age, becomes shrill and 
tremulous ; and the 

" Big manly voire, 
Turning again towards childish treble, pipes 
And whistles in his sound." 

A diminution of tone is also exhibited in the 
muscular coats of the alimentary canal ; the 
stomach and intestines are habitually more di- 
lated ; that is, they do not so readily contract 
upon their contents, when but little is contained 
in them. The same is the case with the bladder, 
which remains large, even when void of urine. 
The diminution of power in the muscular fibres 
of the bladder is productive of a double evil ; as 
it is rendered less capable of retaining the urine 
when distended, and also less capable of com- 
pletely emptying itself. Together with this 
want of power, the bladder often gets irritable 
in advanced life : and to this increased irrita- 
bility the enlargement of the prostate often con- 
tributes, by impeding the action of the sphincter, 
and lessening the diameter of the canal of the 
urethra. 

But muscular contractility is itself intimately 
connected with the condition of the nervous sys- 
tem ; and before we can form a proper estimate 
of the causes that occasion the decline of the 
muscular powers, we must take into consideration 
those that affect, in corresponding periods, the 
nervous powers. 

The structure and composition of the brain 
undergo, by the progress of age, changes no less 
great and important than those that affect other 
parts. The substance of this organ, at the time 
of birth, is almost fluid ; so that, when taken out 
of the cranium, it has hardly sufficient consistence 
to retain its figure. As the body grows, it acquires 
greater consistence and firmness ; in the same pro- 
portion, we may observe that a smaller quantity 
of blood circulates in its vessels. Jn the p 
of life this condensation still proceeds, and the 
subdivisions of that organ are more distinct!* 
marked ; hence, in advanced acre, the brain be- 
comes better adapted for the anatomical study of 
its minuter parts. The distinction of colour be- 
tween its medullary and cortical portions is more 
strongly marked, and is particularly visible in the 
optic thalann, the corpora striata, ihe eornua am- 
moms, and in that portion of the lower patl of 



AGE. 



65 



the third ventricle which gives origin to the 
peduncle of the pituitary gland. 

An alteration also takes place in the chemical 
properties of the substance of the brain j Bichat 
remarks that chemical re-agents act more slowly 
upon the brain of the adult than upon that of an 
infant This is more particularly the case with 
the dissolving power of alkalis, which is much less 
in the former than in the latter. The blood-vessels 
and membranes of the brain become more tough 
and rigid, and are often incrusted with osseous 
deposits. The dura mater is easily detached from 
the inner surface of the skull, in consequence of 
the obliteration of most of the vessels that estab- 
lished a connexion between them. It is only at 
the sutures that it remains attached : and even 
there the connexion becomes less firm as the su- 
tures become themselves obliterated by the progress 
of ossification. The pia mater and tunica arach- 
noides acquire greater thickness 5 and the former 
presents a redder appearance than formerly ; a 
circumstance which offers a marked contrast with 
the diminished quantity of blood in the sinuses and 
neighbouring parts. In general the whole mass 
of brain is diminished in size in advanced age, so 
that it does not completely fill the cavity of the 
cranium. Sometimes, indeed, a contrary change 
to that above described is observed to take place, 
the brain of very aged persons being found in a 
softer and more flaccid state than in the adult ; but 
this should be considered rather as a diseased state 
than the natural effect of age. 

The nerves undergo changes from age very 
analogous to those of the brain ; though, perhaps, 
less distinguishable, in consequence of the mem- 
branous covering with which each of their fila- 
ments is invested. The proportion of nervous 
matter appears to be diminished ; as is certainly 
the case with the number and size of their blood- 
vessels. The ganglions connected with the nerves 
become harder, and of a deeper grey colour, and 
shrink considerably in their size. 

The functions of the several parts of the nervous 
system are, doubtless, dependent on their organi- 
zation ; but no knowledge we have been able to 
obtain of the nature of that organization from ana- 
tomical inquiry, or from any other mode of inves- 
tigation, has thrown any light whatever on the 
mode in which these functions are conducted. 
We cannot, therefore, predict, except in the most 
general way, what modifications of function will 
result from any observed alteration of structure in 
this system. All the knowledge we can attain on 
this subject must be that derived from direct obser- 
vation, and from induction of the facts so obtained. 
Now, the whole series of phenomena that charac- 
terize the decline of life, indicate the gradual dimi- 
nution of the energy of the nervous system in 
general, and of the brain more especially. All the 
sensitive functions are performed less perfectly. 
The organs of the external senses become less 
capable of receiving impressions from their respec- 
tive objects ; the nerves transmit more tardily and 
more feebly these impressions to the brain ; and 
the perceptions to which the transmitted impres- 
sions give rise arc less vivid and more transitory 
than formerly. 

The sensibility of the system generally is di- 
minished by age. Bodily sufferings, from the 
same causes, are less acute ; and equal injuries 
excite less constitutional disturbance ; inflamma- 



tion is more languid. Painful affections, such as 
cancer, are felt less acutely in age than in the 
meridian of life, and these, as well as all other 
diseases,, have a disposition to assume a more 
chronic character. The system is less susceptible 
of the action of contagions of all kinds; and if, by 
a certain age, it has not gone through the usual 
course of exanthemata, and other diseases which 
affect the body only once in the course of life, it 
generally escapes them altogether. 

The temperature of the body is probably lower 
in age than in youth. An explanation of this 
fact has been sought, for in the diminution of the 
quantity of fat, which, by its non-conducting pro- 
perties, prevents the escape of heat from the body : 
but it seems more reasonable to account for it by 
the decline of the powers both of the circulation 
and of the nervous energy in general. Whatever 
be the cause, chilliness is a very common attend- 
ant on old age. It might, perhaps, be concluded, 
from reasoning a priori on the facts already stated, 
that the more easy exhaustion of the sensitive 
powers would call for a greater proportion of sleep, 
in order to restore and maintain them. Yet we find, 
in reality, that old persons sleep less than those 
that are young, and that their sleep is much less 
profound, and oftener disturbed by dreams. Pro- 
bably, the explanation may be found in that law 
of the economy which appears to regulate the 
quantity of sleep by the necessity that exists for 
nutrition. Thus, when the body is growing, as in 
young children, sixteen hours out of the four-and- 
twenty are passed in sleep. Adults sleep, on an 
average, seven or eight hours ; but for the aged, 
five or six hours are generally sufficient. Many 
exceptions, indeed, occur to this, as well as to 
every other rule in which the operations of the 
nervous system are concerned ; and especially in 
those depending so much upon habit, which is 
justly esteemed a second nature. Persons of great 
age sometimes experience very distressing wake- 
fulness ; this is often the effect of cold feet, indi- 
gestion, or other internal sources of irritation. 

The mind, as well as the body, is wasted by 
time. The first indication of diminished vigour in 
the intellectual faculties is usually the decay of the 
memory. The power of recollection, which is 
immediately dependent upon that of association, 
appears to have a closer relation to the physical 
condition of the sensorium, than any other of the 
mental faculties : for we often observe a failure of 
memory, while the judgment continues unim 
paired. This loss of power is chiefly felt in the 
case of new associations. Thus recent events are 
recalled with much greater difficulty than old ones; 
and new habits can hardly ever be contracted. 
The earliest notice that is given of this partial 
decline of the faculties is generally in the forget- 
fulness of the names of persons. When carried 
somewhat farther, the names of tilings are with 
difficulty recollected. The mind loses that com- 
mand of language which it formerly poss 
hence the tardiness of speech, and heaviness of 
expression which characterize the conversation of 
so many persons of advanced aae. The garrulity 
of old persons is also frequently a consequence of 
the deficiency of memory, which cflaces the recol- 
lection of what has just been said, and leads to 
continual reiteration of the same ideas. 

Not only are the bodily feelings impaired by 
age ; the mental sensibility is also blunted, in fti 



64 



AGE. 



least an equal degree, in all that relates to present 
or recent impressions. Yet it has often been 
remarked that old persons feel acutely the loss of 
former friends and companions. How often do 
we not witness the survivor of an aged couple 
soon follow his partner to the tomb ! The failure 
of the sight, of the hearing, the senses which con- 
nect us most largely with the external world, con- 
tribute much to the diminished exercise of the 
intellect, by abstracting the occasions for exertion ; 
and we well know that, without exercise, the intel- 
lectual as well as the bodily powers stagnate and 
become torpid. To this cause are often added 
impediments to bodily exertion arising from rigidity 
of the membranes, stiffness of the joints, debility 
of muscles, and impaired nervous energy. The 
tottering steps and tardy movements of the infirm 
old man can be accompanied with none of the 
enjoyment which attends the exertions of limbs 
animated by the elastic spring of youth. If, under 
these circumstances, he should unfortunately be 
deprived of the resources of mental cultivation, can 
we wonder that he is drivt n for refuge to the 
enjoyment of those senses of taste and smell that 
yet remain ; and that he devotes himself to the 
cultivation of the pleasures of the table, and the 
artificial excitation of spirituous liquors ? Yet 
even here nature imposes certain limits, beyond 
which the votaries of luxury are forbidden to pass. 

" Time hovers o'er, impatient to destroy, 
And closes all the avenues of joy. 
In vain their gifts the bounteous seasons pour, 
The fruit autumnal, and the vernal shower; 
With listless eyes the dotard views the store, 
He views, and wonders that they please no more. 
Now pall the tasteless meats anil joyless wines, 
And luxury with sighs her slave resigns." 

Need we pursue this " strange eventful history'' 
to the last melancholy chapter of man's existence, 
and contemplate the wreck of those exalted facul- 
ties which ennoble his nature, and of which the 
deprivation lowers his condition far beneath that 
of the beasts of the field ? JXeed we dwell upon 
the sickening spectacle of " second childishness 
and mere oblivion ;" and disclose those mournful 
contrarieties of our nature, that drew forth the 
exclamation from the poet — 

• In life's last scene what prodigies surprise ? 
Tears of the brave and follies of the wise. 
From Marlborough's eyes the streams of dotage flow, 
And Swift expires a driveller and a show." 

Let us rather draw a veil on this humiliating 
picture of the frailties incident to humanity, and 
which forcibly remind us of what 

" We shun to know, 
That life protracted, is protracted woe." 

To revert, then, to the philosophical question 
which has already occupied our attention, lei us 
inquire whether it is possible, throughout the mul- 
tifarious changes we have described as character- 
izing the several stages of the transition from 
infancy to decrepitude, to discover the uniform and 
progressive operation of any single principle. 
Admitting that the increasing density of the cel- 
lular substance is the natural consequenee of the 
diminished force of circulation, aided, perhaps, by 
the increased, or, at least, undiminished power of 
absorption, may we not advance a step farther, 
and ascribe the diminution of the force of circula- 
tion to the gradual loss of muscular power arising 
from a decline in the energies of the nervous sys- 
tem I If this be a legitimate inference, then this 
declension of nervous power, which takes place 



with more or less rapidity as we advance in life, 
appears to he the general principle we were m 
quest of; that is. the ultimate fact to which all 
others are subordinate. Appearances, then, war- 
rant the hypothesis that a certain slock of vital 
force is imparted to the embryo at its first forma- 
tion, as a provision for carrying it through its 
destined career of existence. In every action of 
the system a portion of this power is expended ; 
and the greater the expenditure, the less must 
there be remaining, till, at length, the whole being 
consumed, all movements cease, like those of a 
watch which has run down, and of which the 
main spring has ceased to act. 

That considerable differences exist in the stock 
of vitality originally imparted to the frame in 
different individuals, cannot be doubted ; some 
being destined to a shorter, and others to a longer, 
term of existence, independently of all adventitious 
causes that may occur to disturb the regular course 
of nature in the demolition of the fabric, and the 
termination of life ; while others, born with more 
feeble stamina, yet highly excitable, anticipate the 
natural epochs and stages of life, and, precocious 
in their youth, are doomed to premature senility 
and decay. Such is usually the condition of 
dwarfs, who generally die at an early period, 
bearing all the ordinary marks of extreme old age. 

From all that has been said we may draw the 
conclusion, that the spontaneous decay of the 
body, and decline of its powers invariably attend- 
ing the lapse of years, arise altogether from causes 
that are internal, and interwoven with the very 
conditions and laws of its existence, and are but 
little influenced by external circumstances. With 
inorganic bodies precisely the reverse takes place ; 
they owe to external causes their decumposition 
and destruction. But living bodies perish from 
within, being consumed by the very fire which is 
itself the source of their animation. 

If health be viewed as consisting in the proper 
balance and harmony of all the functions of life, 
it is evident that this condition may exist in all 
ages, and that it is compatible with different de- 
grees of energy in the exercise of those functions. 
Though the powers of the constitution may be 
enfeebled by age, and though the actions may be 
less vigorously performed, yet if they be duly pro- 
portioned to one another, the system must be con- 
sidered as in a healthy condition, and as fulfilling 
the designs of nature in the latter stages of its 
existence. In one respect, however, there is a 
material difference between the health of vouth 
and the health of age ; inasmuch as the former is 
more secure and stable than the latter. In the 
period of youth, it is true, the greater activity of 
the functions often endangers the equilibrium of 
the system ; but then the power of restoration is 
at the same time proportionably more efficient. 
Rich in its resources, the constitution of youth 
rebounds with surprising elasticity from the de- 
pression of a severe illness, and even seems to 
gather fresh vigour from the shock. In advanced 
life, on the contrary, this resilient power is defi- 
cient : the fibres that have been stretched beyond 
the proper limits no longer return to their former 
state; the spring no longer re-acts with a force 
equal to that by which it is extended ; and a dis- 
placement of its particles is productive of a per- 
manent alteration in structure, and of augmented 
incapacity to perform the same extent of action. 



AGE. 



65 



The slighter deviations from the perfectly heal- 
thy structure of the organs, which are the con- 
comitants of age, are of various kinds, and their 
effects may be for a long time insensible. Gradu- 
ally, however, they increase in extent, until they 
manifest themselves by some outward indications 
of disordered health ; obscure, perhaps, at first, 
and apparently evanescent ; yet, recurring at un- 
certain intervals, and acquiring, by degrees, a 
more decided and permanent character, they at 
length attract attention ; and proper means being 
resorted to for the correction of the derangement 
in the functions, the health appears to be again 
restored. 

Still, however, there is left a greater proneness 
to disorder than before. Various excitements and 
exertions which formerly were harmless are not 
so well borne. Slighter causes of disturbance are 
followed by some particular symptom or sets of 
symptoms to which there may exist a predisposi- 
tion in the system ; such as head-ach, lassitude, 
dyspepsia, depression of spirits, palpitation, watch- 
fulness, &c. It seems as if something were go- 
ing wrong, and preparing more serious illness. 
Such is generally the progress of structural dis- 
eases, which steal on by slow and insidious grada- 
tions, producing for a certain interval that unde- 
finable state of impending disorder, which only a 
very attentive and scrutinizing observation can 
detect, but which exists long before that eventful 
period commonly characterized as the breaking 
up of the constitution, or that in which positive 
disease has commenced its hostile incursions. 
Then, indeed, all that our most skilfully-directed 
efforts can accomplish is to repulse the immediate 
aggression, and obtain a truce from that enemy 
which is sure to renew the attack, and to whose 
power the citadel we defend must at last be un- 
conditionally surrendered. 

It has been observed that, independently of any 
positive alteration in the structure of a particular 
organ, there occasionally occurs, at a certain period 
of life, a sudden and general alteration of health, 
which is of uncertain duration, though generally 
of no long continuance, and to which the term 
climacteric disease has been applied. This pecu- 
liar condition has been well described by Sir Hen- 
ry Halford in an essay published in the Medical 
Transactions of the College of Physicians, (Vol. 
iv. p. 316.) This disease, he observes, is better 
characterized in men than in women ; but even 
in the former the period of its invasion is by no 
means constant, for it may occur at any time be- 
tween the ages of fifty and seventy-five. Its com- 
mencement is often apparently determined by some 
occasion of feverish excitement, such as an act 
of intemperance, a fall which seemed at the mo- 
ment to be of no consequence, or even a common 
cold. Sometimes it follows upon a marriage con- 
tracted late in life. But the most frequent pre- 
disposing cause is mental anxiety and suffering, 
the corroding influence of which will eventually 
sap the foundations of the most robust constitu- 
tion. 

The climacteric disease is described, by Sir Hen- 
ry Halford, as being marked by an extraordinary 
alteration in the expression of the countenance, 
by an accelerated pulse, and by a wasting of the 
flesh, without any obvious source of exhaustion. 
Wandeiing pains are felt in the head and chest; 
the trngue is white, the bowels are sluggish, the 

Vol. I. — 9 r* 



nights passed either without sleep, or without the 
refreshment which sleep should bring with it, and 
there is a general feeling of lassitude and of fever. 
There is no deficiency of urine ; yet the legs ofter* 
swell. These symptoms may be of some dura- 
tion ; and may, indeed, proceed so far as to under- 
mine the health to such a degree, that the patient 
sinks under a disease which seems to have no 
other characteristic than that of a general failure 
of the functions. But when, as is most frequently 
the case, the powers of the system are adequate 
to recovery, the symptoms are gradually mitigated 
and disappear. Then is there a return of com- 
parative health and strength, which may last for 
many years. But we may yet always remark that 
the energies of the frame have been permanently 
impaired ; and the impression made upon the 
countenance remains fixed and indelible. 

Such is the climacteric disease in its simple 
form, as it occurs in individuals who have enjoy- 
ed previous health. But when it supervenes upon 
a frame already deranged by habitual illness, it 
often assumes the feature and partakes of the cha- 
racter of the predominant complaint. When thus 
associated with the effects of structural disorder, 
it is always difficult to assign the share that be- 
longs to each specific source of disease ; but the 
existence of the climacteric affection may some- 
times be inferred from the peculiar expression of 
the countenance already mentioned, from the unu- 
sual exasperation of the symptoms appertaining 
to the organic disease, and from its proceeding 
with greater rapidity to a fatal termination. It is 
owing to this frequent complication of previous 
local and constitutional ailments with the evils 
which are the natural consequences of old age, 
that the picture above drawn is not often realized 
in actual observation. 

We shall now proceed to point out the more 
specific diseases to which old age is most obnox- 
ious, and by which life, at that period, is most 
frequently terminated. 

Among the numerous indications of a wavering 
in the equilibrium of the functions incident to the 
decline of life, perhaps the most important are the 
symptoms of disorder in the digestive processes. 
Dyspepsia, in all its varieties, is among the earli- 
est as well as most common of the diseases of 
advanced life ; and its prevalence at this period 
may be traced to many causes, of which the ope- 
ration is sufficiently obvious. The principal of 
these is, undoubtedly, the gradual decline of irri- 
tability and of muscular power which pervades 
the whole system, and in which the fibres of the 
stomach and intestines must of course participate. 
It often happens, that while the powers of assimi- 
lation have diminished, the appetite still continues 
good ; and, consequently, more food is taken than 
can be converted into healthy nutriment. That 
portion which is imperfectly digested being retain- 
ed, tends, by its presence and accumulation, still 
further to impede the due performance of this 
function. The distension of the stomach and 
bowels from flatus, and their continued irritant 
from containing acid or acrid materials, lay the 
foundation of a vitiated habit, and of permanent 
injury to the tone of the organs. Another cause 
' of imperfect digestion may be pointed out in the 
loss of the teeth, and the consequent defective 
mastication of the food. The mischief is often 
J aggravated by the sudden discontinuance ol th« 



60 



AGE. 



salutary exercise which was formerly taken ; and 
by an indulgence in the repose which, after a 

life of exertion, is almost claimed as the privilege 
of age. 

Increasing sluggishness takes place in the peri- 
staltic action of the bowels, more especially it 
exercise be neglected. Hence arises a habit of 
costiveness, and hence are formed accumulations 
in the large intestines, and more particularly in 
the cells and flexures of the colon, which acquire 
a preternatural size from habitual and inordinate 
distension. In this way the foundation is often 
laid for structural diseases, which affect the coats, 
and lead to fatal strictures of the great intestine. 

Another and more frequent attendant upon ha- 
bitual constipation are hemorrhoidal tumours, often 
productive of much suffering, or profuse and dan- 
gerous losses of blood ; and leading, not unfre- 
quently, to fistulous abscesses, which terminate in 
a lingering and fatal hectic. 

Protracted dyspepsia may give rise to hepatic 
disease in all its various forms. The cause by 
which these affections are most commonly deter- 
mined, is the abuse of spirituous liquors. If the 
habit of indulgence in this Promethean poison has 
been already contracted, it is almost certain to 
increase during age, when the cravings of this 
artificial appetite never fail to become more inex- 
orable, and when the power of self-control, toge- 
ther with the other energies of the mind, is gene- 
rally diminished. Yet, provided a foundation has 
not been laid for diseases of the liver at former 
periods of life, cither from the cause just men- 
tioned, or from the influence of a hot climate, it 
does not appear that there exists any particular 
pronencss to this class of diseases in advanced 
life. 

The structural diseases of the liver, like those 
of other organs,' are mostly of a chronic character, 
stealing on by slow degrees ; advancing to a cer- 
tain point with comparative rapidity ; then appear- 
ing for a long interval to be stationary : after 
which they proceed another step, and again stop. 
As a considerable portion of life may he spent 
while they are thus passing through their succes- 
sive steps of aggravation, it is natural to expect 
that their last and more fatal stage should occur 
during the later periods of life, and thus appear 
as the natural attendants upon old age. One 
cause, however, may be assigned for the more 
aggravated symptoms, and more rapid course of 
structural diseases in advanced life ; and that is, 
the greater pronencss to chronic inflammation at 
that period, which may itself be traced to a defi- 
ciency of that conservative power which main- 
tains the healthy balance of the circulation. This 
more diffused and insidious kind of inflammatory 
action is particularly apt to affect the serous mem- 
branes. Hence the aged are particularly liable to 
those dropsical affections which are the natural 
consequences of their inflammatory states. The 
same general principle will account for the ravages 
of cancer being more observable in the aged than 
in others. We find accordingly that a large pro- 
portion of elderly females are destroyed by cancer 
of the uterus or mamma ; while, in the male sex, 
the structural disease which more especially mani- 
fests itself in advanced life is the enlargement and 
scirrno'is induration of the prostate gland, and 
(•specially of its posterior lobe. This latter dis- 
ease, besides being productive of various local 



inconveniences, such as irritation ol the bladder, 
and painful obstructions of urine, frequently preys 
upon the general health, and tends to exhaust the 

constitution. 

The failure of the urinary functions is also 
amon" the more frequent causes of distress in old 
persons of the male sex. The first indication of 
a tendency to gravel is the deposition of uric acid 
in the form of crystals, like red sand, in the urine. 
By degrees concretions are formed in the pelvis 
of the kidney, giving rise to acute pain, and other 
nephritic symptoms arising from inflammation and 
abscesses in the kidneys. When these concre- 
tions descend into the bladder, the well-known 
symptoms of vesical calculus are excited, which 
need not be enumerated in this place. But inde- 
pendently of calculus, the muscular power of the 
bladder is liable to be much impaired in advanced 
life, in a greater proportion than other muscular 
parts. Two evils, apparently of an opposite kind, 
yet both referable to impaired action of some of 
the fibres of the bladder, occur as sources of great 
inconvenience and distress. The one is retention 
of urine, from debility of those muscular fibres 
by which it is expelled ; and the other is the in- 
continence of the bladder, arising from paralysis 
of its sphincter. 

The first indication of a failure in the muscular 
powers of the bladder is the inability to empty 
itself wholly ; some urine always remaining be- 
hind, after every attempt at expulsion. If from 
some accidental circumstance the urine has been 
suffered to accumulate in too great a quantity, its 
expulsion becomes still more difficult, and may 
even be found to be impossible, without the intro- 
duction of the catheter. After the bladder has 
thus been stretched to an excessive degree, its tone 
is much impaired, and is with difficulty recovered; 
and even if the power of retention, to a certain 
extent, is obtained, this power may be accompa- 
nied by incontinence when that quantity is ex- 
ceeded, the urine continuing to come away invol- 
untarily, while there is still a considerable quantity 
retained in the bladder. 

Gout, though it be not exclusively a disease of 
age, should be ranked among those to which there 
is a greater predisposition in the decline of life. 
Chronic rheumatism, and especially that form of 
ii which has been termed nodosity of the joints, 
is more prevalent in aged persons than in others. 

The organ which participates most largely in 
the changes induced by age, and which also sym- 
pathizes most extensively with the stomach, is the 
brain ; and the diseases of this organ probably con- 
stitute, on the whole, the principal source of fatality 
at the advanced period of which we are treating. 
The failure of energy in its functions frequently 
shows itself in the alteration which takes place in 
the state of mind ; in the predominance of more 
gloomy views of things, in habitual despondency, 
in increasing listlessness and lethargy, in confu- 
sion of thought or loss of memory, in heaviness 
and somnolency. Old persons arc subject to noises 
in the ears, to occasional head-ach, and giddiness. 
Partial debility is manifest in some particular or- 
gan of sense or motion ; the sight or hearing fails; 
a feeling of numbness, or tingling, is perceived in 
the extremities; wandering pains are complained 
of in different parts of the trunk or limbs, which 
are ascribed to rheumatism, but which are found 
to follow more the course of the nerves than of 



AIR, (CHANGE OF) 



67 



the muscles, and are sometimes referred to the 
centre of the bones. Sudden and unexpected 
relief is often experienced from these symptoms 
by the discharge of flatus from the stomach or 
intestines. 

All these are but preludes to an attack of a 
more serious character. Palsy or apoplexy sud- 
denly supervenes, and either at once carries off 
the patient, or, if for a time recovered from, leaves 
him but the wreck of his former self. It has been 
computed that about one-fourth of all those per- 
sons who attain the age of seventy are destined 
to perish by this disease. It would appear, from 
a computation made by Dr. Heberden, that apo- 
plexy and palsy have prevailed to a greater extent 
in modern times than formerly ; for the number 
of fatal cases from these diseases, recorded in the 
Bills of Mortality, is now double of what it was 
at the beginning of the last century. 

This is not the place to enlarge upon the causes, 
both remote and proximate, of that class of dis- 
eases ; it will be sufficient to observe that they 
appear connected with a local plethoric state of 
the vessels of the head, and more especially of 
those belonging to the venous system, in conjunc- 
tion with the declension of the nervous power. 
In a large proportion of cases they are accompa- 
nied with perceptible structural changes either in 
the cerebral substance, or in the vessels that sup- 
ply it. Ossific depositions in the coats of the 
arteries of the brain are among the most frequent 
of these changes. 

Various lesser degrees of impaired sensibility 
and muscular energy, occasionally perceptible in 
different organs, and constituting what is called 
partial paralysis, are referable to the same causes. 
Instances occur, in the relaxation of the upper 
eye-lid, which, in consequence, hangs over the 
globe of the eye ; in the dropping of the under- 
lip, which becomes pendulous, and is no longer 
able to retain the saliva ; in the faltering speech 
and tremulous voice, and in the relaxation of the 
sphincter, already noticed. 

Cutaneous disorders frequently make their ap- 
pearance during the decline of life. They would 
seem in general to be more closely connected with 
the condition of the brain and nervous system, 
than with the state of the digestive organs. Of 
these the most distressing and intractable is the 
prurigo senilis, which, though unattended with 
any visible eruption, is often remarkably invete- 
rate, and is the source of incessant and indescri- 
bable torment to the individual whom it affects. 

The heart is frequently found to be diseased in 
elderly persons ; hence arises another train of dis- 
eases, which will be described in their proper place. 
It will be sufficient here to indicate ossification of 
the coronary vessels, or of the valves of the heart ; 
increased size of its ventricles or auricles, and 
dilatation of their cavities; aneurisms or ossifica- 
tion of the coats of the large vessels connected 
with the heart. Collections of water in the peri- 
cardium, the • frequent effect of these organic 
changes, contribute still further to complicate the 
symptoms and augment the danger to life. All 
these occasion more or less impediment to the 
action of the heart ; and the consequent disturb- 
ance of the circulation shows itself in various 

v« ays. 

inflammation in the skin, particularly in the 
extremities, is exceedingly apt to terminate in 



mortification during old age. The toes arc fre- 
quently the seat of this affection. Carbuncle may 
also be enumerated among the diseases to which 
there is a more particular disposition in the ad- 
vanced than in early or middle periods of life. 

The last class of diseases affecting aged per- 
sons, which we shall notice in this brief review, 
are those of the respiratory organs. The relaxed 
condition of the mucous membrane of the bron- 
chi, and the predisposition to a chronic form of 
inflammation, lay the foundation for those pro- 
tracted forms of catarrh, of asthma, and of peri- 
pneumony, which prevail so extensively in persons 
of advanced age. In catarrhus senilis, as it is 
emphatically called, the great abundance of the 
secretion from the membrane both of the lungs 
and nasal cavities, and its peculiar viscidity, which 
demands great efforts for its removal, is the source 
not only of great distress, but also of great ex- 
haustion of strength ; the constitution is frequent- 
ly unable to withstand the repeated aggravations 
of this complaint, which take place in successive 
winters. Under these circumstances, especially 
the supervention of peripneumonia notha is ra- 
pidly destructive of life. The occurrence of that 
species of epidemic catarrh, at times so widely 
prevalent, and which is known by the name of 
influenza, is always extensively fatal to very elder- 
ly persons : indeed, all inflammatory complaints 
affecting the chest are incomparably more danger- 
ous at this period of life. Asthma, which must 
certainly be enumerated amongst the diseases of 
age, is not, at first, or in itself, attended with the 
same risk ; though, in its consequences, it eventu- 
ally contributes to the abridgement of those years 
during which the life of a person of healthy lungs 
would otherwise have been prolonged. 

P. M. ROGET. 

AIR, (CHANGE OF.) Change of air is a 
popular, and when well directed, very powerful 
remedy, in a numerous class of chronic ailments ; 
in some acute diseases ; and in a state of conva- 
lescence from disease generally. Its influence 
also is, perhaps, still more remarkable in removing 
that condition of the system which may be termed 
rather a deterioration of health than a formal dis- 
ease, and which is occasioned by confinement and 
sedentary habits, or residence in impure air ; a 
complaint which has been termed Cachexia Lon- 
dinensis, although by no means peculiar to the 
metropolis. 

The striking improvement produced in the 
health by a removal, or a few weeks only, from 
the tainted atmosphere of a city to the pure and 
invigorating air of the country, is the subject of 
daily observation. Even a change from one part 
of the country to another is often attended with 
remarkable benefit, and that when there is little 
or no apparent diirerence between the two situa- 
tions. 

We use the term pure and impure in this place, 
because unquestionably the atmosphere in various 
situations differs materially in its purity, accord- 
ing to the ordinary meaning of the term. It may 
be true that the air collected in the most confined 
alleys of London, when subjected to analysis by 
the chemist, shall afford the same proportion of 
oxygen and azote as that to be found on the sum- 
mits of our highest mountains ; but we have no 
reason to believe that oxygen and a^ote constitute 



66 



AIR, (C HA KG I- OF) 



the whole ingredients of the atmosphere. The 
present state of our chemical knowledge may not, 
indeed, enable us to determine what is the pre- 
cise nature of the other ingredients, hut we are 
not the less sure of their existence, and that they 
often exert a pernicious influence on health. The 
attempts of chemical philosophers to ascertain the 
nature of the agents now referred to, which con- 
taminate the air in different situations, and speed- 
ily produce specific diseases, or more slowly un- 
dermine the health, have hitherto proved most 
unsuccessful. Even our means of measuring 
some of the obvious physical qualities of the at- 
mosphere are still very imperfect ; so that in treat- 
ing of them we are often obliged to employ the 
terms in common use, instead of the more accu- 
rate and definite language of science. 

[Even the change from a better to a worse air 
has been found serviceable. In Edinburgh, the 
inhabitants of the most airy parts of the New Town 
have frequently sent their children, when labour- 
ing under hooping cough, to the Cowgate — a 
filthy street, which runs at right angles under one 
of the largest thoroughfares in the Old Town, 
and in which, at a certain hour in the night, the 
inhabitants eject all the offensive accumulations 
from their houses, to be washed away by the water 
of the reservoirs let on for the purpose.] 

Although change of air implies some change 
of climate, in the extended acceptation of this 
term, yet by the former expression is commonly 
meant a removal from one place to another in the 
same country or climate. And it is in this more 
limited sense that we use the expression change 
of air on the present occasion. In another arti- 
cle, the medical effects of different climates, and 
of change of climate, will be fully discussed. (See 
Climate.) In the present article we shall con- 
fine ourselves to a few practical remarks on the 
principal circumstances which should guide the 
practitioner in prescribing change of air, in order 
that the patient may derive all the benefit from 
that remedy which his case admits of. It is upon 
the just adaptation of the remedy to the individ- 
ual case that all the advantages to be expected 
from change of air depend. 

In designating the predominating qualities of 
the air in different places, which give to them sev- 
erally a peculiar character, in reference to their 
effect on the human body, we shall employ terms 
in common use, as their import is well understood, 
and they are sufficiently explicit for our present 
purpose. The epithets soft and mild, as opposed 
to sharp and harsh ; moist or damp, as opposed 
to dry ; heavy or oppressive, as distinguished from 
light and elastic, are expressions in general use ; 
and the effects of the conditions of the atmo- 
sphere which they indicate, in soothing or excit- 
ing, in depressing and relaxing, or in exhilarating 
and bracing, are well known by experience. The 
different states of the atmosphere just noticed, 
exert a more powerful influence in proportion as 
the constitution is delicate , and, accordingly, 
change of air becomes a much more important 
remedy in the diseases of such persons. It is, 
indeed, chiefly from observing the manner in 
which invalids and delicate persons are affected 
by the atmosphere of different situations, that we 
ure enabled to estimate its less powerful influence 
on the more robust constitution. 

Habit, and the conservative powers inherent in 



the human system, enable man to resist, to a cer- 
Sl.SU 'IK- action of the deleterious quaht.es 
of the atmosphere ; yet no person, however strong 
Irnv be his constitution, will long remain altoge- 
ther uninfluenced by them. Their effects are tn 
general, observable on the organization of the 
inhabitants of such places, and in the manner in 
which the various functions of life are performed 
in a state of health ; and they are, perhaps, still 
more remarkable in the nature and character of 
the diseases to which such persons are most ob- 
noxious. Although these circumstances are more 
strikingly observed in the natives of different cli- 
mates, they are sufficiently evident in the inhabit- 
ants of different districts in our island. In proof 
of this, we need only compare, in the state of 
health, the firmly-knit frame, the florid counte- 
nance, and the elastic motions of the mountaineer, 
with the sallow complexion and languid gait of 
the inhabitant of the humid plain, or confined 
valley. The contrast is equally strong when these 
individuals are suffering from disease. In the 
former, we have acute, febrile, and inflammatory 
affections ; in the latter, diseases of slower progress, 
with comparatively little excitement of the vascu- 
lar system, but with great sensibility of the nervous 
system. Were any proof necessary that this dif- 
ference depended on the locality, we find it in the 
fact that persons, in removing from one district to 
another, gradually assume the characteristics, both 
of health and disease, of the inhabitants of the new 
locality. For example, the character of the same 
disease attacking the Welsh mountaineer on his 
own hills, will be very different from that which he 
would be subject to after a residence of some time 
on the southern shores of Devonshire or Corn- 
wall. The physician in the metropolis, who has 
constant opportunities of seeing patients from all 
parts of the country, cannot fail to remark how 
much the character of their constitutions and the 
nature of their diseases vary according to their 
place of residence. It is unnecessary to point out 
the important practical bearing of this observation, 
which so happily illustrates the well-known re- 
mark of Baglivi, " differre pro natura lucorum 
genera medicinal." But our attention, for the 
present, must be limited to the consideration of the 
effects of change of air in remedying disease and 
improving the general health. 

The leading circumstances which require con- 
sideration in prescribing change of air, are the 
nature of the disease, the constitution of our 
patient, and the quality of air best suited to these. 
Before noticing these, however, it may he well to 
make a few remarks on the periods of disease a: 
which change of air can be employed with any 
prospect of benefit, or even without disadvantage. 

In acute, febrile, or inflammatory diseases, it is, 
of course, during the stage of convalescence only 
that change of air is proper : but when the con- 
valescence is sufficiently advanced to admit of a 
removal, and the season of the year is favourable 
for such passive exercise in the open air as a con- 
valescent can bear, a case will rarely occur in 
which the return of perfect health may not be 
materially promoted by such a measure. When 
the patient resides in a crowded city, or other 
confined situation, the change is more urgently 
called for ; and, indeed, we feel convinced »hat 
under such circumstances, many cases of severe 
disease occur, after which complete restoration of 



AIR, (CHANGE OF) 



C9 



health is never effected without a change of air. 
The person deprived of the benefit of such a mea- 
sure attains only to a degree of health inferior to 
that which he enjoyed before the occurrence of his 
disease ; and the remainder of his life is often 
little better than a state of improved convalescence. 

In those acute diseases which are accompanied 
with little fever, change of air need not be delayed 
till the patient is convalescent. When the more 
active period of the disease has passed over, and 
the danger of creating inflammation is greatly 
diminished, and more especially when the disease 
threatens to pass into the chronic form, a judicious 
change of air will often assist powerfully in putting 
an end to it. As examples of such diseases, we 
may mention the subacute forms of bronchitis, 
catarrhal affections generally, and hooping-cough 
in particular. But even in these cases the change 
requires to be well-timed : if too early, it will 
scarcely fail to aggravate the disease ; if deferred 
too long, the disease may have fixed itself in a 
chronic form, and the measure, consequently, 
prove much less beneficial than if it had been 
adopted at an earlier period. It is impossible, 
however, to do more at present than to call atten- 
tion to the circumstance ; the medical attendant 
can alone decide upon the proper period of removal 
in each individual case. 

In no class of diseases is change of air so ob- 
viously and imperatively called for as those which 
originate in the pernicious qualities of the air of 
certain localities, commonly, of late years, desig- 
nated by the general term malaria. The most 
conspicuous of this class is the numerous family 
of aguish disorders. In these cases the single 
measure of change of air is often sufficient of itself 
to remove the disease ; and the more promptly the 
change is made, the more effectual it is likely to 
prove. This measure, however, should never be 
trusted to' exclusively in intermittent fever. The 
disease has been produced by a specific cause, and 
generally requires a specific remedy for its com- 
plete cure. If this be neglected, we shall frequently 
find that the disease has only been suspended, not 
cured. The period when the paroxysms are sus- 
pended by the removal of the patient from the 
source of his disease, is the most favourable for 
employing the proper remedies for securing him 
against a relapse. Even when the removal does 
not suspend the disease, it renders it more amen- 
able to the action of medicine ; and, were it only 
with this view, change of air should be adopted in 
such cases whenever it is practicable. The per- 
fect re-establishment of health is scarcely ever 
effected in the severer forms of those diseases, as 
far as our observation goes, without a complete 
change of residence for a considerable time. 

The indiscriminate manner in which change of 
air is recommended, with little regard to the con- 
stitution of the patient, the nature of his disease, 
or of the place whither he is sent, are the principal 
reasons why this measure so often disappoints the 
hopes of the invalid and his friends. It is quite 
essential to success that the air of the place selected 
should be suited to the patient. The feeble and 
irritable invalid will not bear a keen exciting air, 
whatever may be his disease ; whereas the invalid 
possessing a constitution of an opposite character 
will feel increased vigour while breathing such an 
atmosphere. As an example of this difference of 



result in the same disease, we may refer to bron 
chial irritation. In sensitive irritable subject! 
labouring under bronchial disease, we generally 
find a corresponding state of the pulmonary organs; 
we have little expectoration, with a disproportion 
ate degree of irritation and cough from the slight 
est exciting causes. A dry and sharp atmosphere 
in such cases cannot be borne, while a mild and 
even humid air often gives relief. In persons ot 
a more languid habit, suffering under the same 
disease, we find less sensibility of the mucous 
membrane, and a much more copious expectora- 
tion. The same dry and keen air which proves 
so irritating in the former case is beneficial in this. 
Were we to prescribe for the name without giving 
due consideration to the nature of the disease and 
the constitution of the patient, both these invalids 
might be sent to the same place, the one to be 
injured as much as the other would be benefited. 
What has just been said of bronchial affections is 
equally applicable to dyspepsia, rheumatism, con- 
sumption, and several other diseases. It would 
be wasting the reader's time to point out the 
important practical inference to be drawn from 
these observations. 

In recommending change of air, the next cir- 
cumstance which presents itself for our conside- 
ration is, the relative preference to be accorded to 
a situation in the interior of our inland, or on the 
sea-coast. The season of the year will assist us 
in deciding this point. Generally speaking, the 
more sheltered parts of the interior form the most 
eligible residences, to all classes of invalids, during 
the spring and early part of summer : after mid- 
summer, in the autumn, and during the winter, 
the sea-side affords the best situations. This, 
however, is only- to be considered as a general 
rule, to which there are many exceptions. Whe- 
ther the situation selected be inland, or on the 
coast, the particular characters of its air must be 
such as are suited to the patient, as very consider- 
able differences exist in places situated at no great 
distance from each other, both in the interior and 
on the sea-shore. There are also peculiarities of 
constitution, which we can only learn from inform- 
ation communicated by the patient. Some per- 
sons, for example, never feel well by the sea-side 
in any situation, or at any season, although to all 
appearance their ailments are such as we know to 
be generally benefited by a marine atmosphere ; 
while others improve during a residence on the 
coast under the most unfavourable circumstances 
of situation and season. 

But there are few persons who require change 
of air, either with the view of preventing disease, 
or of removing its effects, that will not derive 
greater benefit from repeated changes, than from 
a long continued residence in any one situation, 
however judiciously selected. The more sheltered 
and drier parts of the interior during the spring, 
the more elevated and even mountainous districts 
in the summer, and the south and south-west 
coasts of our island during the autumn and winter, 
afford a succession of changes capable of effecting 
much benefit in numerous cases in which the. 
other measures of medicine are of little avail. It 
is to be regretted, however, that but a small pro 
portion of invalids, or of the more delicate of oui 
youth, can avail themselves of a change of air 
upon so extensive a scale as we have just been 



70 



AIR, (CHANGE OF) 



contemplating; the rather because it affords one 
of the most powerful means of improving the 
general health, and obviating the disposition to 
tuberculous disease, which we possess. 

But here it is proper to observe that the best 
directed change, or succession of changes, of air, 
will produce little permanent benefit unless strict 
attention be paid to regimen, more especially as 
regards diet. Too much is generally expected 
from the simple change of air, while little atten- 
tion is paid to the various circumstances compre- 
hended under the term regimen, although these 
are equally essential to the restoration to health as 
the measure from which so much is anticipated. 
It should be strongly impressed on the minds of 
such persons as seek benefit from change of air, 
and more especially upon dyspeptics, the most 
numerous class of all, that, without adhering to 
the regimen laid down for them, they will derive 
but little advantage from the most favourable 
change of air. Many may, indeed, find their 
limbs stronger and their general health improved, 
and even the more urgent symptoms of their dis- 
ease may cease to prove troublesome ; yet all these 
improvements will too often prove but fleeting, and 
their return to their usual avocations will soon be 
followed by a return of their old complaints. 

The restricted limits of this article will not 
allow us to particularize all the diseases in which 
change of air proves useful ; there are few, indeed, 
to which it is not applicable at some period of 
their course. The good effects of this remedy, 
when well directed, in the morbid states of the 
mucous membrane of the respiratory organs, are 
well known ; and they are scarcely less remark- 
able in disorders of the digestive organs, and of 
the uterine system. In the functional derange- 
ments of the nervous system, also, whether origi- 
nating in the diseases just alluded to, or the conse- 
quence of sedentary and confined life, change of 
air will be found a powerful means of restoring 
the tone of the system. In all these cases, indeed, 
it is a remedy for which we have no adequate 
substitute. 

[In all diseases in which the affection appears 
to be kept up by habit, in other words, by accus- 
tomed associated actions, and especially in those 
that implicate the nervous system, the beneficial 
effects of change of air are proverbial, and are 
acquiesced in by all observers. 

It is probable, that a great portion of the salu- 
tary effects ascribed to the waters of fashionable 
summer retreats is dependent upon change of air, 
and other extraneous circumstances. Long before 
the citizen of one of the Atlantic towns reaches 
the Alleghany springs of Virginia, he has an 
earnest of the advantages he is about to derive 
from change of air ; and many a valetudinarian 
finds himself almost restored during the journey. 
rig as it is, through the mountain regions 
which have to be crossed before he reaches the 
White Sulphur, in Greenbrier county. Many 
S too, cannot drink the water with impu- 
nity, and are consequently indebted for their im- 
piovement chiefly to change of air, but somewhat, 
also, to varied scenery and society, absence from 
cares of business, and to greater regularity of living, 
j^erhaps, than they have been accustomed to. In 
making these observations, it is not designed to 
affirm that mineral waters, as in the ease of the 



valuable spring in question, may not occasionally 
be important agents in the cure of disease j hut. 
taking invalids in general, we are satisfied that 

more is dependent upon change of air than upon 
the administration of the waters. The inhabitant 
of one of the Atlantic cities, and of most of the 
districts to the cast of the Blue Ridge, removes 
from a hot atmosphere to one which is compara- 
tively cool, and where all the diseases that arc 
common to hot and malarious climates are ex- 
tremely unfrequent, and many of them unknown. 
The advantage is obvious. He escapes the dis- 
eases which might have attacked him had he 
remained through the summer in his accustomed 
locality ; and hence the wealthy families of Lower 
Virginia are in the habit of spending those months 
in the mountain regions in which they are espe- 
cially liable to disease in their own malarious dis- 
tricts. We can thus understand the reputation 
acquired by the inert Bath and Matlock waters of 
England, the latter of which has scarcely any 
solid ingredient ; and yet what crowds flock to 
these agreeable watering-places ; to the former, for 
the perpetual amusements, that keep the mind 
engaged, and cause it to react beneficially on the 
corporeal or mental malady ; to the latter, for the 
erfjoyment of the beauties of nature, for which 
Derbyshire is so celebrated. It is obvious, that 
were such waters bottled, and sent to a distance, 
so that the invalid might drink them at his own 
habitation, the charm would be dissolved. The 
garnitures — more important, in this case, than the 
dish — would be wanting, and the banquet would 
be vapid, and without enjoyment or benefit. Less 
than twenty years ago, amidst the bubbles that 
were engaging the minds and the money of the 
English public, it was proposed to carry sea-water, 
by means of pipes, to London ; in order that the 
citizens might have the advantage of sea-bathing 
without the inconvenience of going rhany miles 
after it. Had the scheme been carried into effect, 
the benefits from metropolitan sea-bathing would 
not have exhibited themselves in any respect 
comparable to those of the same agent employed 
at Brighton or Margate. (Dunglison's Elements 
°f Hygiene, p. 157. Philad., 1835.) 

It would seem, therefore, that a mere change 
of the physical circumstances of the atmosphere 
in which we arc habitually placed, is advantageous 
to the economy, and that the vital forces act with 
increased energy, whenever we leave a locality to 
which we have been long accustomed, and where 
the functions are executed under the influence of 
unvaried excitants, and pass to one differing essen- 
tially from it. Nor is it always necessary that 
this difference should be extensive. Sir James 
Clark remarks, (The Sanative Influence of Cli- 
mate, &c, 3d edit. p. 315: Lond. 1841,) that 
notwithstanding the uniformity of temperature 
which prevails among many of the West India 
islands, the effect of a change from one to another 
is often very remarkable in improving the health, 
— a fact frequently observed on a large scale, 
among the British troops stationed in the West 
Indies ; and he considers, that one of the most 
powerful means of diminishing the sickness among 
the troops, in that climate, would be to remove 
them frequently from one healthy island to an- 
other. 

The moral and ] V.ysical effects of change of air. 



ALOPECIA. 



71 



during travelling, have been well depicted by Dr. 
James Johnson. (Change of Air ; or the Philo- 
sophy of Travelling, &c. ; Ainer. edit. : New- 
York, 1831.)] 

But change of air is not more valuable as a 
remedy in the cure of disease and its consequen- 
ces, than as a preventive of disease, more espe- 
cially in childhood and youth. At this tender 
and susceptible period of life, the rapid influence 
of the atmosphere in which we live, in deteriorat- 
ing or improving the health, is very remarkable ; 
a change of a few weeks from the country to a 
large town being often sufficient to change the 
ruddy, healthy child into a pale, sickly-looking 
creature, and vice versa. The comparative in- 
fluence of a town and country air on the health 
of children is seen in a striking manner in the 
families of the higher ranks of society, who spend 
a considerable part of every year in town. Chil- 
dren should never be reared in large towns, when 
this can be avoided ; and when unavoidable, they 
should be sent, during a part at least of every 
summer, into the country, which, indeed, is the 
proper place for children, until their system has 
acquired sufficient strength to resist the injurious 
effects of city life. When they cannot have this 
advantage, we consider it the duty of the medical 
attendants of families to urge a temporary annual 
residence in the country, as essential to the health 
of children, more particularly those who are deli- 
cate. How many neglect this invaluable means 
of improving the health of their offspring, who 
have it in their power, and would willingly adopt 
it, were they aware of its importance ! So strong- 
ly, indeed, are we impressed with the value of this 
measure from ample observation, that we consider 
parents resident in towns, who have the means of 
giving their family the advantage of country air, 
and neglect it, deficient in one of their chief 
duties. To young females, who, by the habits of 
society, are much more confined to the house than 
boys, a temporary annual residence in the coun- 
try becomes a measure of still greater importance, 
and should be continued at least to the full period 
of their growth. We have reason to believe that 
the advantages of country air to the young and 
delicate are not yet sufficiently appreciated by the 
profession, and we are therefore anxious to call 
their attention to it, that they may use their in- 
fluence with the public, upon whose minds if they 
succeed in impressing the full value of pure air, 
they will be the means of contributing greatly to 
the health of the rising generation. 

James Clark. 

ALOPECIA.— The falling off of the hairs, in 
an unusual degree, from any part of the body 
naturally covered with them, constitutes the essen- 
tial character of this disease. The name, which 
is derived from n-XuT^f, vulpes, because the fox, 
when grown old and during summer, has been 
observed to be subject to this complaint, has, since 
the time of Sauvages, been used as the generic 
term of the disease ; but, by the Greeks and 
Celsus, it was originally confined to one of its 
species.* 

* De Mfdicina, lib. vi. cap. 4. Actius, Tetrab. 2, 
Scrrno 2, 55. Pho, de cogn. et curand. morbis, lib. i. 
cap. 1. Orilms. do Inc. affect, cur. lib. iv. rap. 42. Paul. 
Jib. iii. cap. 1. Serapion. lib. i. cap. 1. Mcrcurialis, lib. 
i. cap. 4 ; lib. vi. cap. 4. 



Syx. Fluxus Capillorum, Area; {Celsus) ; 
Tyria (Arab.) ; Athrica, Depilatio, Defluvium 
Pilorum, Pelada, Pilarella (Auct. Var.) ; Pelade 
(Parte) ; Alopecia (Sauvages) ; Calvities (Teu- 
tonici) ; der Kahlkopf, (Plenck) ; Trichosis 
Area (Good) ; Gangrena Alopecia (Young) ; 
Baldness. 

The different manner in which the hairs fall, 
the state of the skin from which they fall, and 
the healthy or unhealthy state of the hairs them- 
selves, lead to considerable variety of form in the 
disease. Sometimes the hairs are shed irregular- 
ly and indiscriminately, producing only a general 
thinness of the hair ; to this Celsus applied the 
descriptive term, fluxus capillorum.-f Sometimes 
parts of the body are entirely deprived of their 
hairs, presenting smooth shining patches perfectly 
bald ; these are the ares of Celsus, (Lib. vi. cap. 
4.) the alopecia areata of Sauvages, the porrigo 
decalvans of Willan. When the spots of bald- 
ness observed no particular form, although usual- 
ly they are nearly circular, they were denoted by 
Celsus, after the Greeks, d\6ircKia ; £ but when 
they presented a lengthened serpentine form, gen- 
erally commencing on each side of the occiput, 
and sometimes continued until they united in 
front, the term dpiavis was applied to them.§ 
Sometimes this disease is universal, leaving not a 
single hair upon any part of the body ; ( Welt's 
Tr. Soc. Med. and Chi. Kn. ii. 264.) in which 
case it was called, by the French, la pelade,- 
although some will have it that, with the falling 
of the hair, a desquamation of the cuticle was 
also meant by this term. Sometimes the baldness 
is confined to one particular part, most commonly 
to the hairy scalp, when it formerly received the 
name of <pa\dKpu>ois or wutSapuxn? ; sometimes to 
the eye-brows, eye-lashes, or other parts of the 
body. The fall of the hairs may take place more 
or less rapidly ; sometimes in a few days, and 
even in a shorter period, the body has been known 
to lose all its hairs ; sometimes the change is slow 
and imperceptible. Sometimes the skin, from 
which the hairs fall, presents the ordinary appear- 
ance — smooth, shining, without redness or altera- 
tion ; sometimes it is pale, of a dead white colour, 
and furfuraceous ; sometimes it is covered with a 
scaly scurf like pityriasis, which, when removed, 
exposes an erythematic appearance ; sometimes 
the skin is natural in sensibility, and sometimes 
it is affected with itching, or a sense of pricking 
or pungent acrid heat. Sometimes the hairs, 
before falling, as well as those which remain, pre- 
sent an unhealthy appearance ; at other times no 
alteration can be perceived in them, and those 
which surround the bald spots are as strong and 
healthy as natural. Nor are these distinctions 
trivial or of little help ; for they are all connected 
with particular causes and particular conditions 
of the body, and, therefore, lead to precision of 
treatment. 

The immediate cause of the falling of the hairs 
is unquestionably a diseased state of the follicles 
which nourish and support their bulbs, having the 
same relation to them as the capsule or membrane 

! Lpc. Citat. lib. vi. cap. 1. Trallian. i. 2. Actual 
M. M. ii. 5; iv. 9. Orihas. iv. 5. Fernel. Consul, i. 1 

J Id. loc. citat. Oaten, de Cur. Morb. sec. loc. lib i 
cap. 2. 

§ Ccteus, loc. citat. Oribas. de Loc. Affect. Cur. *» 
42; viii. 22, 24. Jctuarius, M. M. v '■■' 



72 



ALOPECIA. 



which sun jnds the roots of the teeth, (for the 
]irocess of the formation of the teeth and the hair 
is perfectly the same) ; but the precise nature of 
the diseased state has not been determined. It 
would seem to depend sometimes upon inflamma- 
tion of the follicles, sometimes upon their ulcera- 
tion, sometimes upon a temporary deficient action, 
and sometimes upon atrophy or death of the folli- 
cles. In the body of a man who had become 
almost entirely hald in consequence of a putrid 
fever, of which he died, Bichat observed all the 
pilous follicles in their natural state, and small 
hairs shooting forwards from their bottom ; but he 
remarks that, before the fall of the hair in aged 
people, the cavity of the bulbs of the hairs gradu- 
ally diminishes, and the follicles, which contain 
the bulbs, at last disappear. The destruction of 
the pilous follicles may, however, be caused by 
pressure, by friction, and by other causes. Thus 
it has been observed to be produced by the pres- 
sure of certain subcutaneous tumours. 

Alopecia may be a purely local and idiopathic 
disease ; the affection originating in the follicles 
themselves. This happens when it arises from 
external causes, as from the application of quick 
lime or other depilatories ; from the fumes of 
quicksilver, as was observed by Forestus in gold- 
smiths ; from exposure of the head to the rays of 
the sun ; from frequent pressure of weights upon 
the head ; and from friction of any hairy surface 
by the garments or otherwise. Or it may be local 
and consecutive, as when the follicles are injured 
by becoming involved in the inflammation, ulcera- 
tion, or other morbid process of any adjacent 
cutaneous disease, as happens in porrigo, im- 
petigo, variola, eczema, elephantiasis, and several 
others. 

Alopecia may also be secondary and symptom- 
atic, a consequence of general debility and con- 
stitutional exhaustion ; and hence it attends the 
convalescence of febrile diseases, and the puer- 
peral state ; hence, also, it is a common symptom 
of the advanced stage of phthisis, of diabetes, and 
of most cachectic diseases ; thus justifying the 
prudence of the Komans, who estimated slaves 
affected with alopecia at the lowest price. Hence 
it is also observed in the nervous debility which 
follows excessive venereal indulgences or seminal 
emissions, and has been known to be produced by- 
painful and distressing headachs ; by long con- 
tinued and intense study ; by the depressing pas- 
sions, as fear; by cares, disappointments, and 
anxiety. Of this kind was evidently that singular 
case related by Ravator, of a person, who, after a 
violent commotion, was attacked with amaurosis 
of the right eye, and all the hairs of the same side 
of whose body lost their colour, and fell from the 
eye-brows and eye-lashes as well as from the head. 
Of the same nature, also, was, in all probability, 
the remarkable case of M. le Chevalier d'Epemny, 
(Gazette Francois, Feb. 23, 1763.) who, after an 
assiduous application for the space of four months, 
without any previous symptom of disease, lost his 
beard, his eye-lashes, his eye-brows, and, in short, 
all the hair of his head and body. 

Alopecia may be a sympathetic affection, not 
a symptom of a constitutional disease, but caused 
by a disease or disordered state of some other 
organ or system of organs. The most common 
t>nn of this description which has come under 



our observation, is that which proceeds from 
chronic inflammation of the mucous membrane of 
the stomach, giving rise to a particular form of 
dyspepsia, which has, for this reason, been called 
inflammatory. Of this nature, probably, was 
that mentioned by Galen, (De Cur. Morb. Sec. 
Loc. lib. i. cap. 2.) arising from eating poisonous 
mushrooms; and that other noticed by Hippo- 
crates, (De Internis Affectibus, sect. 4.) in which 
the reader will readily recognize a well-marked 
case of the above-named form of dyspepsia (gas- 
trite chronique), and to which case there is, in an 
excellent record of modern medicine, (Journal des 
Progres, 1830. torn. ii. p. 43.) a parallel in form 
as well as in cause, and which, it is deserving of 
attention, was afterwards succeeded by an attack 
of diabetes mellitus. Of the e-ime nature also 
was in all probability that species of alopecia 
termed by the Arabians (Avenzoar, Avicenna,) 
bilious, in contradistinction to the other species 
which they called phlegmatic ,- which last, in all 
appearance, corresponded with that form described 
by Celsus as most difficult of cure, "pejus est 
quod densam cutem et subpinguem ex toto gla- 
brum facit," coinciding with the observation of 
some modern writers, that if the skin is pale or 
insensible, and it is difficult by friction to produce 
redness, the case is irremediable. Of the same 
nature is the case given by Lemery, of a man, 
who, some months after excessive catharsis, lost 
successively all the hairs from his body ; and also 
another strikingly singular case, which, both in 
its causes and its cure, justifies the opinion which 
we have ventured to give of the nature of this 
species of alopecia. It is so illustrative that no 
apology is required for relating it. " Lodovico 
Gnemmi, a Piedmontese, fifty-seven years of age, 
a person of great vivacity of temper, of a plethoric 
habit, but spare form of body, having the skin of 
a dull white colour, began, in the winter of 1825 
and 1826, to feel severe pains in the head, with a 
sensation of burning heat over all the body, but 
most particularly in the skin : it was to such a 
degree, that, during the coldest night of winter, 
he was obliged to throw off his bedclothes. After 
having passed fifteen days in this painful state, he 
began by degrees to lose all the hairs of his head, 
then those of the beard, eye-brows, eye-lashes; 
and in the course of a month, there was not to be 
found a hair upon the surface of his body, neither 
in the arm-pits, on the breast, on the genital organs 
surrounding the anus, nor upon any of his extre- 
mities. All his skin was as smooth as polished 
marble, and the slightest trace of hairs could not 
be felt by the hand. He remained for two years 
in this state, so deformed by the loss of his hair 
that he hardly ventured to show himself in public, 
but always feeling on the surface of his body a 
sense of pungent acrid heat, more especially on 
the surface of the scalp, which was always mor- 
bidly sensible and painful to the touch. ' In the 
beginning of March, 1828, he was attacked with 
a severe peripneumony, which was treated and 
cured by the most active antiphlogistic remedies, 
viz. : low diet, general and local blood-letting, 
cupping, purgation, blisters, &c, and, strange to 
say, under the influence of this treatment, on the 
decline of so severe an inflammatory disease and 
in a state of the greatest weakness of the circula- 
tion, the hairs which had disappeared for the 



ALOPECIA, 



73 



6pace of two years, began again to shoot forth, 
and continued to do so during all his conva- 
lescence. On their first appearance they resem- 
bled fine soft wool, almost colourless wool ; but 
they continued every day to approach nearer to 
their natural character, which they had fully re- 
covered at the end of a month, when, owing to 
some imprudence in regimen, he was seized with 
an acute attack of gastro-enteritis, which carried 
him off." (Journal des Progres, torn. xiv. p. 244.) 

Of the same nature, also, are many cases of 
partial alopecia (porrigo decalvans) which we 
have observed in adults as well as in children, and 
which we have had the satisfaction of remedying 
by treating the primary disease — chronic gastritis, 
or inflammatory dyspepsia. 

This origin of alopecia also accounts for the 
connexion which we have observed between it, 
lichen, urticaria, and pityriasis ; sometimes co- 
existing ; sometimes succeeding each other ; all 
differently modified operations of the same cause. 
To this description of alopecia ought probably 
to be also referred' those which have been attri- 
buted to the use of certain kinds of food, and 
which have been said to prevail at particular 
places. Thus it is said not to be unfrequent in 
countries where the inhabitants live chiefly on 
fish ; as, for instance, formerly in the Shetland 
Islands, where baldness from this cause was so 
common that it was a familiar saying that " there 
was not a hair between them and heaven." (»SVr 
R. Sibbald's Description of Shetland.) Thus 
Tournefort relates, that in the island of Mycone, 
one of the Cyclades, the children are either bald, 
or seldom arrive at the age of twenty without 
being so. And, though it is difficult to assign the 
cause, it must be acknowledged that alopecia 
(porrigo decalvans) has appeared to be more com- 
mon at Brighton than in other places, and that all 
the cases the writer has observed in this place 
have afforded symptoms of chronic irritation of 
the mucous membrane of the stomach. 

Besides the causes of alopecia which have been 
enumerated, in distinguishing its different kinds, 
there is one which has been observed by Dr. 
Willan and others, not easily referred to any of 
them. It is when the disease appears to have 
originated in the infection of porrigo scutulata ; 
for when this disease has spread through large 
schools, in some instances, one or two of the 
children have been affected with alopecia (porrigo 
decalvans 1 ). We have purposely avoided placing 
amongst the causes of alopecia the influence of 
age, which belongs more to the ordinary course 
of nature than to a process of disease, as well as 
another cause which is said to have a wonderful 
power in modifying the growth of the hair. We 
allude to the circumstance of eunuchs, when the 
mutilation takes place in infancy, having no 
beard, and yet never becoming bald ; a change 
which is more properly considered a deformity 
than a disease, but showing a singular connexion 
between the growth of the hair and the develop- 
ment of the genital organs, of which, however, the 
perfect state of the body affords many proofs. 

There is, however, one species of alopecia 
which, properly speaking, ought to have been 
arranged amongst the symptomatic forms of that 
disease, but which, on account of its specific 

Vol I 10 g 



nature, has generally been separated from it — 
alopecia syphilitica. The falling of the hairs is 
one of the most rare of the secondary symptoms 
of syphilis, so much so that it is seldom met with 
— not oftener, it has been calculated, than once in 
fifteen hundred cases. M. Cullericr, of the Hopi- 
tal des Veneriens at Paris, who was for twenty- 
five years in the habit of seeing from two to three 
thousand venereal patients every year, states that, 
upon the whole number, he had not met with 
more than three or four cases of universal alopecia, 
and from fifty to sixty cases of partial alopecia.. 
Nor was it observed amongst the symptoms of 
that disease upon its first appearance in Europe ; 
for, either unknown or at least unnoticed before, 
it was not until towards the year 1538 that it 
attracted the attention of observers — of Rangon, 
Fallopius, Massa, Brassavola, and Fracastorius. 
From that period it seems to have gone on in- 
creasing to the end of that century or to the 
beginning of the next, since which time it has 
been progressively decreasing, and has almost 
entirely disappeared in temperate climates ; but. 
if we may place confidence in some accounts, it 
is less rare in warmer regions, as in Egypt, the 
southern provinces of Italy, and Spain. It is 
however not entirely unknown amongst us. Cases 
are to be found in the works of most medical 
writers; one of the most recent is that of Professor 
P. Metons. (Clinique Chirurgicale.) 

When this form of alopecia first fixed the 
attention of observers, it was matter of dispute 
whether it was a consequence of the disease or of 
its specific remedy ; but though it appears, par- 
ticularly from the cases of Forestus, that alopecia 
may be produced by mercury, there are not want- 
ing cases to prove that it has followed syphilis 
when this remedy had never been resorted to ; and 
its cure by mercury is a strong converse proof 
that, if it ever arises from it, it is only under very 
peculiar conditions. 

The syphilitic alopecia does not in itself present 
any peculiarity to distinguish it from the other 
forms of that disease. It is generally preceded or 
accompanied by a furfuraceous state of the skin, 
from which vast quantities of small scales are 
daily thrown off", in the form of bran, and daily 
reproduced, and the skin underneath is observed 
to be redder than natural. But the cotemporane- 
ous existence of other symptoms of the venereal 
disease, and the history of the case, will afford the 
best data for diagnosis. 

It might be inferred, from the great number and 
the diversity of the remedies which have been 
used and recommended for the cure of alopecia, 
that the method of cure was very uncertain, or the 
forms of the disease very diversified. As the con- 
clusion is usually drawn from these premises, this 
latter inference is generally overlooked. But if we 
admitted it, as we ought, it would lead us not 
always to throw aside the multifarious farrago of 
our predecessors as so much useless rubbish, but 
direct us to seek in the varieties of the forms of 
disease for the reasons of the application of such 
various remedies ; and, in our opinion, by recor. 
ciling in this way the diversity of the disease with 
the diversity of the methods of treatment, we should 
entertain a better opinion and make a better use 
of past experience. 



A L P E C I A — A L T E It A T I V E S . 



Treatment. — From the distinctions of the 
different forms of alopecia which we have endea- 
voured to point out. may easily be understood how 
it may sometimes have been cured by phlebotomy; 
by local depletion, as leeches, scarifications, and 
acupuncture ; by purgatives, low diet, and other 
antiphlogistic remedies : how, at other times, 
simple local means may have succeeded better, as 
friction, no matter whether with the fat of the 
mole, the snake, the hedgehog, or the bear ; or 
with warm exciting substances, as camphor, tur- 
pentine, naphtha, laudanum, resin; with volatile 
oils, as those of laurel, rosemary, mace, or cinna- 
mon, or with the distilled water of bees-wax; with 
acrid substances, as thapria, euphorbium, staves- 
acre, nasturtium, mustard -seed, garlic, onions, 
and tincture of tobacco ; with irritating applica- 
tions, as friction with fig-leaves, nettles, tincture 
of cantharides, and even the application of a blis- 
ter : how at other times advantage may have heen 
derived from alkaline ingredients, which explains 
the use .tf the laxivia of wood ashes, of burnt cane, 
of the burnt hair of bears, and of applications 
containing the bile of different animals, and the 
ordure of birds, as the ancient remedy of stercus 
columbinus: how at other times such astringent 
applications as alum, cimolian earth and wine, or 
green vitriol, the atramenium sutorium of Celsus, 
may have answered better ; and how, whatever be 
the form of the disease, or the nature of the treat- 
ment, the frequent shaving of the diseased parts, 
which has been recommended by all writers, is a 
remedy always applicable. 

When there exist signs of an inflammatory 
state of the pilous follicles, or erythema of the 
surrounding skin, leeches may be applied with 
benefit, and a course of purgative remedies is of 
great service. But when the disease of the folli- 
cles appears to arise from an inflammatory state 
of the mucous membrane of the stomach, leeches 
must be applied to the scrobiculus cordis, and a 
regimen of mild bland diet must be insisted upon. 
In the first case the best local application is any 
mild demulcent liquid, as decoction of bran, or 
mallows. But when the skin, from which the 
hairs fall, indicates a deficient degree of vitality, 
the parts may be excited by local stimulants. 
(R old maris gii. alcohol : giv. M.) Pencilling 
the surface with a solution of nitrate of silver, or 
rubbing it with a liniment of olive oil, and as 
much nitric acid as makes it pungent, but not 
acrid, have been found to answer the same pur- 
pose. Of the use of the celebrated oil of Macas- 
sar in such cases we have no experience, but the 
solution of sulphate of copper in alcohol, lately 
very much recommended by a German physician, 
has failed in our hands. When the skin is fur- 
furaceous, or the cuticle hard, shining, and imper- 
meable, like parchment, it is of great use to wash 
it frequently with some alkaline or sulphurous 
solution (R Liq. ammonias acctcrfis f.^ii- ammo- 
nix carbonatis gii. alcohol.- f.^ss. aq. fontan : 
f-fy iv. fiat lotio.) But when either of the foregoing 
slates of the skin is connected with a deranged 
state of the general health, it is unnecessary to say 
that this demands the chief attention. 

When alopecia acknowledges a syphilitic ori- 
gin, the specific remedy of that disease must be 
Dad lecourse to exhibited in as mild a form as 



possible. For the direction and i .cans ol effecting 
[his we refer to the treatment of Acs E syphilitica. 
The local applications in this form of the disease 
differ in no respect from those suited to the ordi- 
nary species, except that a few grains of corrosive 
sublimate mav sometimes be advantageously com- 
bined with them ; and frequently shaving the 
diseased skin is a part of the treatment which 
cannot be dispensed with. rp j Todd. 

ALTERATIVES. — This term, although not 
expressive of a distinct class of medicines, is s< 
frequently employed as to require particular ex- 
planation. By an alterative course of treatment 
is commonly meant the continued exhibition of 
certain medicinal agents supposed to have the 
power of altering certain disordered actions, chiefly 
of a chronic character ; and all medicines possess- 
ing, or supposed to possess, such a property, no 
matter to what class in the Materia Medica they 
may otherwise belong, are occasionally denomi- 
nated alteratives. Although the term is often 
used vaguely, the indication with which an altera- 
tive medicine is prescribed is of the utmost im- 
portance. It might be said, indeed, in general 
terms, that all remedial means whatever are 
alterative, but the alteration sought from the use 
of specific alteratives, or of alteratives in the re- 
stricted and ordinary acceptation of the term, is 
such as is not readily, or at all, to be obtained, by 
general or local bleeding, by purgatives or diu- 
retics, by tonics, anodynes, or antispasmodics ; 
although the agency of particular medicines be- 
longing to any of these classes is sometimes made 
subservient to an alterative course of treatment. 

Mercury, in all its various forms, is one of the 
medicines most commonly employed as an altera- 
tive ; and the great influence it exerts on the 
whole economy, over all the secretions and excre- 
tions, and over the nervous system itself, consti- 
tute it an alterative, when prudently given, of a 
most efficacious kind. Even in certain states of 
fever, mercury has been employed with success 
for the restoration of the secretions, and, there- 
fore, it may be said, as an alterative. In chronic 
inflammation, although here, perhaps, the term 
alterative may be objected to, small doses of the 
pilula hydrargyri or of calomel are often consid- 
ered highly serviceable : no cases are more fre- 
quent than these, and in none is the practitioner 
more in need of some means of checking or alter- 
ing actions, which, although neither violent noi 
immediately dangerous, are silently effecting struc- 
tural changes and irreparable mischief. It would 
certainly appear that, for this purpose, the major- 
ity of practitioners rely on the efficacy of mercury, 
often in combination with opium. In certain in- 
stances, of which chronic laryingitis may be cited 
as an example, as well as in the instances of new 
formations, even of a malignant character, the 
addition of a medicine possessing narcotic proper- 
ties may be useful on the principle of allaying the 
disturbance of the nervous system. a disturbance 
but little regarded or acknowledged in such cases, 
but probably intimately connected with the pri- 
mary functional disorder in which all morbid 
changes of structure, and even inflammation itself, 
must commence. Most persons of experience in 
medicine have met witii examples of chronic dts- 



ALTERATIVES. 



75 



orders of a troublesome rather than of a danger- 
ous nature, which have been ameliorated, or en- 
tirely relieved, by the persevering use of some of 
the forms of mercury ; although the medicine 
may have been given at first without any other 
reason than that it afforded a chance of benefit. 
Even irritable states of the bronchial and intesti- 
nal mucous membrane certainly sometimes give 
way under this treatment; but the application of 
it requires that caution of which nothing but ob- 
servation can teach the value. The advantage 
obtained in such cases, and in others not unfrc- 
qucntly met with, from the apparently indiscrimi- 
nate employment of calomel, may eventually be 
found to depend upon some general law, which 
has not yet been explained ; or simply, as we be- 
lieve John Hunter thought, one kind of irritation 
superseding another, and banishing it from the 
system. No medicine is so commonly given in 
disease of the mesenteric glands as calomel ; it is 
by no means rarely administered in scrofula ; not- 
withstanding the general opinion of the unfavour- 
able influence of mercury on the scrofulous con- 
stitution ; and notwithstanding the common ac- 
companiment with mesenteric disease of a state 
of intestinal irritation or of chronic inflammation. 
In almost every varied disturbance of the liver, 
mercury is one of the first medicines to which 
many practitioners have recourse, and in the form 
of the pilula hydrargyri it has been recommended 
in many disorders of the digestive functions. A 
practice so common must have been supported by 
many cases in which it was found useful, although 
the principle on which the medicine acts, if it be 
not that of suspending morbid actions, is, in some 
of the cases, not very easily imagined. In the 
case in which acute inflammation of membranous 
parts is checked by the employment of calomel ; 
or depositions, the consequences of such inflam- 
mation, are removed, of which iritis may be men- 
tioned as presenting a striking illustration ; this 
medicine is given to produce a precise effect, which 
experience has shown to arise from its use. In 
the chronic forms of indigestion, its operation on 
the secretions seems to explain the great advan- 
tage often arising from it. In the other cases, 
cases of mere irritation, or cases in which there 
is a disposition to new formations not ascribable 
to inflammation, the same medicine is given, often 
with the same good effects ; but the actions which 
are then interrupted being less understood, the 
medicine is only called an alterative. 

Antimony is very often employed in the class 
of cases just spokftn of, although not in them ex- 
clusively, as an alterative ; generally in combina- 
tion with calomel. The benefit of this combina- 
tion is usually ascribed to an alterative effect pro- 
duced by them in the secretions into the intestines, 
and in the cutaneous exhalation ; in other words, 
in the functions of the bowels and the skin. The 
pulvis antimonialis is, perhaps, most frequently 
used with this indication in extemporaneous pre- 
scription ; and a very useful preparation, the anti- 
monii sulphuretum pracipitatum, is conveniently 
united in the pilula hydrargyri sub-muriatis com- 
posita, with calomel. In this, the celebrated Dr. 
Plummer's pill, we meet with another alterative 
in the guaiacum, which, as well as the sassafras, 
the mczcrcon, and sarsuparilh although not so 



extensively useful, is certainly of singular utility 
in some chronic affections. Daily observation 
shows the obvious effects of the Plummer's pill 
on the bowels and on the skin : the most observ- 
able of the immediate effects of the sassafras and 
the sarsaparilla are produced on the skin, although 
some effect may occasionally be observed equally 
early on the intestinal and renal secretions. The 
taraxacum is a medicine not unfrequently given 
in chronic affections of the stomach or the liver ; 
and its sensible, as distinct from its alterative ac- 
tion, appears to be greatest on the urinary secre- 
tion. In the alkalis we have another description 
of medicines, often prescribed as alteratives, par- 
ticularly to scrofulous patients affected with dis- 
ease of the glands of the neck or of the mesen- 
tery, or with diseases of the joints. The carbo- 
nates of soda and potass, and sometimes the liquor 
potassse or the liquor calcis in combination with 
sarsaparilla, or with some of the bitters, are pre- 
scribed in such cases, and probably produce their 
good effects by first acting on the stomach itself 
But there can be no doubt that all these medicines 
have an ultimate effect which in reality entitles 
them to the name of alteratives. This effect, 
which ma)' be simply expressed by the phrase of 
altering morbid actions, may be secondary to their 
action on the stomach, or on the skin, or on both 
these surfaces ; or it may be primary. Accurate 
observations on the states of the blood in disease 
are too infrequent to enable us to speak with con- 
fidence of the alterative effects of medicines on 
that important fluid. It is, however, highly pro- 
bable that the effects of some at least of the alter- 
atives are secondarily, and of others primarily 
produced on the blood itself. In many of the 
diseases in which they are most employed, and 
most useful, there is an evident impairment of 
secretion. Secretion, although partly dependent 
on certain nervous actions, demands, for its per- 
fect performance, a healthy state of the blood, the 
fluid in which and out of which all the various 
constituents of the various secretions are creited. 
Supposing that from some disorder in the blood, 
we have produced, certain varieties of disease on 
the surface, or in the stomach or intestines, or in 
the bones, ligaments, cartilages, or other solids of 
the body, — the effect of a medicine which removes 
such diseases must be to alter that first morbid 
condition of the blood ; and thus to cause healthy 
secretion and excretion, instead of cutaneous dis- 
ease, or chronic indigestion, or venereal nodes in 
the tibia, or increased vascularity and depositions 
affecting the motions of the joints, or any other 
morbid action or formation for the prevention or 
cure of which we prescribe alterative medicines 
Such, then, generally speaking, must be the ac- 
tion of alteratives. They may amend the state 
of the blood by previously improving the functions 
of digestion and assimilation ; or they may directly 
affect the process of sanguification, a process yet 
imperfectly understood ; but that alteratives do 
actually change and improve the state of the blood 
in many instances cannot lie doufeted. We find 
in such facts, admitting them to be so, an expla- 
nation of the term depuration, attenuation, &c, 
used by the older writers, and also of the more 
popular expressions of ■• sweetening" and of 
" clearing" the blood ; and in these terms we have 



76 



ALTERATIVES. 



a pn>of how long such an opinion has appeared 
reasonable to pathologists, and how supported the 
opinion is bj common belief, founded upon com- 
mon observation. 

But supposing the nervous action which has 
been spoken of, as essential to the proper perform- 
ance of secretion, to be disordered in cases in 
which alterative medicines are commonly consid- 
ered to be indicated, — it may still be understood 
how this functional office of the nervous system 
may also be more efficiently performed when an 
alterative medicine has corrected the disordered 
state of the intestinal canal ; and there are not 
wanting facts of a nature to incline us to ascribe 
the influence of some medicines employed as alter- 
atives, to their direct operation on the nerves. 
Whether the use of hemlock in the case of some 
tumours, and the effects of the prussic acid in cer- 
tain examples of phthisis pulmonalis, may not be 
of this kind, is at least worthy of some consider- 
ation. That the addition of a small quantity of 
the extractum hyoscyami, or of the pulvis ipeca- 
cuanha compositus, to alterative doses of the pilu- 
la hydrargyri, in certain forms of dyspepsia, is 
serviceable in this way, seems hardly to admit of 
doubt. 

Physicians of great authority, among whom 
may be mentioned Dr. Heberden, have laid it down 
as a rule to be observed in the management of 
obstinate chronic disease, that we should with all 
care regulate the different functions of the body, 
diligently observing any departure from their com- 
mon and healthy condition ; and thus place the 
constitution as nearly as we can in that state in 
which its own efforts may be put forth for the cure 
of such persevering and otherwise intractable mal- 
adies. It may at least be said, that this is often 
all that the practitioner has it in his power to do ; 
and it might sometimes be advantageous to the 
practitioner, as well as to the patient, if the former 
would limit his ambition by recollecting this. If 
the obscurity in which internal changes are effect- 
ed, weakens the evidence in many medical cases, 
the annals of surgery abound with instructive 
proofs of the extraordinary local benefit arising 
from this kind of treatment. This is that consti- 
tutional treatment, in fact, which Mr. Abernethy 
succeeded in introducing into surgical practice ; 
and although the disciples of that distinguished 
pathologist, and even he himself, may sometimes 
have carried the principle too far, its foundation 
is not weakened either by their erroneous zeal or 
by his eccentricity. 

Another rule, less scientific, and less safe, and 
emanating from authority less to be depended upon, 
is, when a disease does not readily yield to com- 
mon treatment, to make some great impression on 
the constitution, in the hope that, in the general 
commotion and agitation, disordered actions may 
be rudely interrupted, or the actions of health feli- 
citously restored. Without entering into any 
discussion concerning the propriety of the rule, 
which might perhaps admit of justification even 
as leading merely to the introduction of a new 
irritation, its principle is unquestionably alterative. 
Various means have been employed to produce 
the desired effect, — a large bleeding, a large dose 
of mercury, a powerful opiate, or repeated and 
large doses of metallic tonics. All of these, and 



other measures adopted with the same intention 
have we doubt not, been occasionally serviceable 
Of ,| K . advantageous operation of some of then 
we have been witnesses ; particularly of the us, 
of a large dose of mercury in very obstinate sci 
atica, and of opium in some old and unmanage 
able cases of epilepsy. 

There are certain auxiliaries to medical treat- 
ment, which are frequently used with all the in- 
dications which have been specified as pointing to 
the employment of alteratives. Thus, chance of 
air, sea-bathing, alterations of habitual clothing, 
and sudden or considerable changes in diet, are 
frequently recommended, and with the best effects 
sometimes producing benefit by acting on the 
stomach or on the skin ; sometimes by acting 
more directly on the blood, or on the nervous 
system ; sometimes by improving the state of the 
secretions or excretions ; sometimes by removing 
some obstacle to the proper performance of some 
particular function ; and sometimes by producing 
a new and strong impression on the body or the 
mind. Many of these advantages are simultane- 
ously obtained by taking the various mineral 
waters. Change of place, and temporary change 
of habits, freedom from business, and the gentle 
excitement of novel forms of amusement, doubt- 
less very powerfully conspire to produce the sin- 
gular improvement of health so often observed in 
patients resorting to Cheltenham, Leamington, 
Tunbridge, Malvern, Harrogate, and other cele- 
brated watering-places ; although still a part, and 
often a very considerable part of the improvement 
is evidently to be ascribed to the daily and mode- 
rate excitement of the stomach and bowels, and, 
in some cases, of the kidneys, by the ingredients 
of the mineral water itself, which thus acts as a 
most valuable alterative of the whole system. 
That the external application of the waters 
stimulates the skin to new action, and thus pro- 
duces direct relief, and, in this way, or by sym- 
pathy, improves the tone of the stomach, or effects 
more, extensive improvement, must also, we pre- 
sume, be admitted. 

The class of chalybcates contains agents which 
have an evident effect on the circulation, as tonics. 
Given, however, in the minute state of subdivision 
in which they are held in solution in natural 
springs, they produce effects which entitle them 
to the name of alteratives. They excite the cir- 
culation, which was before languid, and, in all 
probability, they alter and improve the condition 
of the blood. Either directly, or through their 
first action on the sanguiferous system, or by 
seme direct or indirect influence on the actions 
of the nervous system itself, or in more than one 
of these ways at once, they stimulate the secre- 
tions, which were before scanty and imperfect; 
and they more manifestly alter the state and ap- 
pearance of the body than any other medicines 
whatever. In conditions of the body suited to 
their use, no alteratives are, in fact, so effectual 
They substitute general energy for general debility, 
and revive the colouring of health in patients 
before pallid, or wan, or discoloured, as in the 
chlorotic, by long disease. The illustration of an 
alterative by reference to remedies of this class, 
shows, however, the impossibility of effectually 
dividing alteratives from other classes of medicines. 



ALTERATIVES. 



77 



When medicines are intended to act as altera- 
ti »es, they are usually given in small doses, re- 
peated every night for some weeks ; such, at least, 
is the general mode of prescribing alterative doses 
of calomel and the antimonial powder. From 
two to five grains of either are frequently pre- 
scribed in this way, to adults, but most common- 
ly the smaller dose of both. Five grains of the 
Plummer's pill contain rather more than one grain 
of calomel and of the precipitated sulphuret of 
antimony, and two parts of guaiacum. In many 
cases of disordered digestion, small doses of the. 
pilula hydrargyri (gr. ii. or iii.) are given every 
night or every other night, or still smaller doses 
twice or thrice a day. None of these medicines 
can properly be employed without interruption for 
more than a few weeks : if their good effects are 
not perceived in that time, a perseverance in their 
use will hardly ensure them ; their use may, how- 
ever, be suspended for a week or a fortnight, and 
then advantageously resumed. The young prac- 
titioner should, however, very carefully endeavour 
to distinguish those cases in which an alterative 
plan of treatment affords any prospect of amend- 
ment, from those in which the loss of time in its 
ineffectual trial will prove injurious. The mind 
is prone to any belief which favours indolence ; 
and there are practitioners who content them- 
selves with the delusion that no treatment, except 
the alterative treatment, is really efficacious in 
any chronic case. 

Another error, not very uncommon, is the pro- 
tracted employment of medicines of this sort. 
Their effects, not being suddenly produced, are 
sometimes overlooked ; or being brought about 
very gradually, and long expected in vain, they 
are at length watched for with less diligence, and 
disregarded when they might be discerned. The 
complete discontinuance of an alterative is of 
course best indicated by the desired improvement 
taking place in any case. When such medicines 
are properly applied, (and no medicine is useful 
but by timely application,) indications of their 
general effects, and even of their mode of action, 
may clearly be perceived. The tongue, for in- 
stance, loses its morbid coating ; the appetite im- 
proves ; the bowels become more regular ; the 
skin grows smoother or freer from eruptions ; 
the mind becomes more cheerful ; the patient 
sleeps better; and the countenance becomes ex- 
pressive of that feeling of general comfort which 
is incompatible with chronic disease, and arises 
from the due and healthy performance of all the 
bodily functions. Unless some of these effects 
result from the use of alterative medicines, after a 
reasonable continuance, the practitioner should 
carefully inquire into the cause of such failure. 
He will probably find it in some local disorder, 
not to be removed without local treatment, and 
which he ought to have recognised at an earlier 
period. On the other hand, when the signs of 
amendment which have been mentioned appear, 
it should be recollected that to persevere in the 
use of alteratives is to apply to the body, in a 
state of health, actual causes of disease. It would 
seem superfluous to notice such plain and obvious 
particulars, if observation did not show us that, 
from the neglect of such plain and obvious things, 



rather than of things less on the surface, mistakes 
are daily committed. 

With respect to the guaiacum, which has been 
enumerated among the alteratives, and which has 
a very ancient reputation, it is not easy to ascer- 
tain its precise share in the good effect produced 
by the compound calomel pill. Except in that 
formula, its application is nearly limited to certain 
cases of chronic rheumatism, in which, we fear 
it must yet be allowed that Dr. Ferriar's observa- 
tion concerning it is correct ; and that, whilst 
there certainly are some forms of the disorder ir 
which its effects are excellent, it very frequently 
seems to have no effect at all. The tinctura 
guaiaci ammoniata, in doses of one or two 
drachms, is the most common form in which this 
medicine has been employed in rheumatic cases, 
We have ourselves little to say of its efficacy 
when used alone ; and we so often remark, when 
doubt has been once cast on the operation of a 
medicine, and the effect is carefully looked for, 
that it fails to be observed, as much to wish that 
not only the guaiacum, but many or most of the 
articles in the Materia Medica were submitted to 
new and careful clinical experiments. No part 
of medicine is in more need of complete reform 
than that which relates to the actual effect of 
medicines daily and hourly employed. 

The sassafras, like the guaiacum, is not often 
prescribed as an alterative by itself; it enters, with 
the mezereon, into the composition of the com- 
pound decoction of sarsaparilla, a medicine of 
great value in a very large class of cases. This 
decoction seems, in English practice, to have 
superseded the once famous Lisbon diet-drink, of 
which sarsaparilla and the sulphuret of antimony 
were among the principal ingredients. This is 
not one of the alteratives of which the good 
effects are to be expected from small < ses. In- 
deed there is reason to think that disappointment 
has sometimes arisen from the decoction of sarsa- 
parilla having been given in too small a quantity. 
In ordinary cases, the patient is required to take 
a pint of the compound or of the simple decoc- 
tion daily ; and three or five grains of the Plum- 
mer's pill, or three grains of the pilula hydrargyri, 
or five grains of the hydrargyrum cum creta, or a 
few grains of calomel and antimony, are common- 
ly prescribed to be taken at night during the use 
of it. But if it is desired to ensure the full effect 
of the decoction of sarsaparilla, and particularly 
if its operation is solely trusted to, the patient 
should be persuaded to drink two, three, or four 
pints a-day, and sometimes even a greater quan- 
tity. 

An alterative plan of treatment generally com- 
prehends the use of some of the medicines spoken 
of in this article. Others are occasionally em- 
ployed with the same intention, but it is unneces- 
sary to dwell upon them, for it will be seen that 
the line of division is, after all, rather artificial 
than real. Whatever medicines may be employ- 
ed with this indication, it should be remembered 
that the proper regulation of the patient's diet, 
and strict attention to nil the articles of regimen, 
are indispensable auxiliaries ; the effects to be ex- 
pected from this kind of care being indeed ouvj 
ously analogous to those of alterative* 



[For alteratives, a term — as often used — con- 
veying no distinct moaning, Dr. DunglisoD has 
substituted euirophics, promoters of healthy 
nutrition. See Euthophics.] j Conolly. 

AMAUROSIS, from aftavo6oi, to obscure. This 
is the name applied to one of the diseases of the 
eye, in which defective vision depends on impair- 
ed sensibility of the retina. The term gut/a 
terena has also been applied to this disease, from 
an erroneous notion that the dark enlarged pupil, 
which sometimes accompanies it, is a drop of 
black fluid which interrupts the passage of light. 
In practice, when a patient without opaque cornea, 
closed pupil, or cataract, complains of lost or 
defective vision, he is considered to suffer from 
this disease. 

Viewing the exquisitely delicate organization 
of the retina, and the origin, course, and compli- 
cated connexions of the optic nerve, it is not sur- 
prising that impaired vision should so frequently 
be produced by disease in some part of the nervous 
apparatus. The ultimate fibres of the optic nerve, 
expanded into a membrane of extreme tenuity, 
supported and disposed upon a membrane of 
nearly equal delicacy, from whence it derives its 
vascularity, and covered and separated from the 
neighbouring choroid by a tunic of still greater 
delicacy, present altogether a piece of anatomical 
organization most likely to have its functions im- 
paired by slight deviations from the natural or 
sound condition. Disorganization of the hya- 
loid membrane, upon which this delicate struc- 
ture rests, or of the choroid, with which it is ex- 
ternally in contact, may also materially affect its 
condition. The optic nerve, with its vascular 
and membranous accompaniments, enclosed in a 
sheath of fibrous membrane in its course through 
the orbit, pierced by the central artery, and close- 
ly connected with other arteries and nerves, is 
exposed to many injurious deviations from the 
natural structure. The same optic nerve within 
the head, from the vicinity of large vessels, and 
its complicated nervous connexions at the place 
of decussation, the tuber cinereum, the crura 
cerebri, the thalami, and the tubercula quadrige- 
mina, is liable to suffer from disorganization of its 
own structure, as well as of any of those parts 
with which it is connected. A review of the 
structure of the nerve of vision, from its origin at 
the tubercula quadrigemina to its anterior termi- 
nation at the ciliary processes, is the best pre- 
liminary exern.je for one about to study the dis- 
ease of amaurosis. 

Injury or disease of the brain, as ruptured 
vessels, serous effusion, softening, tumor, or ab- 
scess, frequently impair the functions of the optic 
nerve, although such injury or disease should 
exist in a situation remote from the origin or 
course of the nerve. Amaurosis may, therefore, 
be a consequence of cerebral disease, although 
the optic nerve should be sound from its origin 
to its termination. [Lawrence on Diseases of 
Hie Eye, Amer. edit. p. 478 : Philad., 1843.] 

Injury or disease of a nerve, or morbid con- 
dition or irritation of particular organs, affect in- 
juriously the brain and nervous system, and thus 
impair the functions of the retina : hence amau- 
losis from gastric, hepatic, or uterine disturbance. 



AMAUROSIS. 

"The experiments of Magendie, inconclusive 
as they are, and often proving too much for 
the hypothesis they are intended to strengthen, 
at least show that the fifth pair of nerves exerts 
some very important influence on the function of 
vision ; pathological observations on this subject, 
although few in number as yet, lead to the same 
conclusion, and the effects of injury of the frontal 
nerve in producing amaurosis, long since observed, 
establishes the fact. Ptosis, depending on disease 
of the third pair of nerves, is always accompanied 
by defective vision. 

' Arterial and venous vascularity is an essential 
part of the organization of the retina, as it is of 
the whole nervous system ; the existence of large 
vessels carrying red blood in a structure of such 
delicacy and transparency is even a remarkable 
circumstance, when contrasted with the apparently 
bloodless condition of many other white or trans- 
parent structures. Increased arterial action, or 
obstructed venous circulation, may, therefore, ma- 
terially affect the condition of the retina, and im- 
pair its sensibility. 

There is great variety in the perfection of vision 
in different individuals ; which may be attributed 
partly to a difference in sensibility of the retina, 
but in a still greater degree to a difference in pow- 
er of adaptation of the eye to distance. It ap- 
pears a great mistake to suppose that this differ- 
ence in perfection of vision depends altogether on 
the power of adaptation. A difference in perfec- 
tion of vision is often observed in persons who 
appear to enjoy an equally perfect power of adap- 
tation. A single lens remedies, in a great desree, 
the defect arising from want of power of adapta- 
tion ; but no single lens will confer on a landsman 
the distant vision of a sailor, nor on a long-sight- 
ed person the power of distinguishing minute ob- 
jects enjoyed by some near-sighted persons. It 
is scarcely reasonable to suppose that any altera- 
tion in curvature or relative positions of the cor- 
nea, or lens, in birds, can take place sufficient to 
account for the great superiority in vision which 
these animals enjoy. The sight of nocturnal ani- 
mals, and of persons who can see perfectly in 
obscurity, can only be attributed to a superior sen- 
sibility of the retina, as it is altogether independ- 
ent of any superior power of adaptation. 

The sensibility of the retina is increased by two 
totally different causes, — permanent exposure to 
a strong glare of reflected light, or a long-contin- 
ued residence in a darkened apartment. The 
inhabitants of snowy countries are obliged to 
adopt the precaution of protecting the eyes by 
means of a goggle, with a slit opposite the pupil, 
and the inhabitants of towns in which the build- 
ings are white are said to suffer from inflammatory 
affections of the eyes. Persons immured in dun- 
geons are said to acquire a power of distinguish- 
ing even small objects in their obscure abodes, in 
which, at first, they could not delect even a glim- 
mering of light. The morbid sensibility of the 
eye to light, in what is called scrofulous ophthal- 
mia, is in a great degree to be attributed to the 
injudicious exclusion of light from the eye by the 
use of shades, or confinement in a darkened room. 
The effect of light and shade upon the sensibility 
of the sound retina is beautifully exemplified by 
the simple experiment of directing the eve to 



AMAUROSIS. 



?J 



some opaque object intervening between the ob- 
server and the light If the eye be fixed for a 
few minutes upon the sash of a window, upon 
turning it in a different direction, a luminous im- 
age of the opaque sash remains. In this case the 
glare of light poured in through the glass on the 
unshaded part of the retina renders it less sensi- 
ble, while the part shaded by the opaque sash re- 
tains its original sensibility ; all the retina is after- 
wards exposed to the same quantity of light, yet 
to that part which was shaded it is a glare, while 
the part previously exposed to a stronger light has 
its sensibility blunted. If this explanation be 
correct, it is at variance with the fact previously 
stated, that exposure to the glare of reflected light, 
from snow or whitened buildings, raises the sensi- 
bility of the retina. The sensibility, however, 
produced by exposure in snowy countries appears 
to be morbid and permanent, probably connected 
with slight inflammatory action. That inflamma- 
tion of the eye is accompanied, in many cases, by 
morbid sensibility of the retina, is confirmed by 
daily observation ; and we have cases on record 
of persons being enabled to read, even in the dark- 
ness of night, in consequence of accidental injury 
producing inflammation. Amaurotic patients, suf- 
fering from inflammation, often observe an im- 
provement in vision while the inflammation con- 
tinues, which ceases as it subsides. 

These and many other facts and reasonings, 
which might be brought forward, prove that the 
retina in its most healthy and natural state is en- 
dowed with different degrees of sensibility under 
different circumstances, and, therefore, there can- 
not be any difficulty in admitting that morbid 
changes, however slight, may materially alter its 
functions. The facts stated, also, show that an 
acquaintance with the structure and functions of 
the retina must be the foundation of our know- 
ledge respecting the disease under discussion. 

The discussion of the causes of amaurosis in- 
volves so many details, and presents so many ap- 
parent contradictions, that some arrangement of 
the materials becomes absolutely necessary. A 
primary division into organic and functional has 
been suggested, and has been insisted upon by 
Mr. Travers in particular. This has been object- 
ed to, and justly, on the ground that, although 
we have abundant evidence of the occurrence of 
the organic disease, yet, that it remains to be prov- 
ed whether there is any disease purely functional, 
any disease which does not depend on structural 
or organic alteration, however temporary. For 
practical purposes we believe the distinction to be 
good. Daily observation proves that the func- 
tions of organs become instantaneously suspended, 
and as suddenly restored ; and this has repeatedly 
occurred in the case of the retina. 

By those writers who do not attempt any ar- 
rangement of this intricate subject, or who adopt 
an imperfect one, amaurosis is attributed to num- 
berless causes apparently directly opposite in na- 
ture : to inflammatory action and vascular tur- 
gescence from general plethora, or to debility from 
hemorrhage : to menorrhagia or to amenorrhcea : 
to suppressed perspiration, healing of large ulcers 
or issues, sudden suppression of the secretion of 
milk, or to discharge from piles, nursing, diar- 
rhoea diabetes, ptyalism, or venereal indulgence: 



to the removal of cutaneous eruptions, or to the 
occurrence of gastric or intestinal irritation, exan- 
thematous diseases, dentition, or worms : to preg- 
nancy, or to total suspension or abolition of the 
uterine functions : to exposure to strong light, or 
to confinement in darkness : to drunkenness, nar- 
cotic poisons, direct rays of a hot sun, muscular 
efforts, grief, joy, fear, rage : to wounds or irrita- 
tion of nerves of the orbit, especially of the oph- 
thalmic branch of the fifth pair; to neuralgia, 
tooth-ach, or to total paralysis of those nerves : 
to hydrocephalus, hydrothorax, hereditary predis- 
position, hysteria, typhus fever : to metastasis of 
various diseases, as gout, rheumatism, and many 
others. 

If the primary division into organic and func- 
tional be good, it should afford us some clue to 
this labyrinth. The division, organic amaurosis, 
must obviously include those varieties of the dis- 
ease which depend on alteration in structure of 
the retina or of the optic nerve to its origin, em- 
bracing inflammation of the retina and its conse- 
quences, increased vascularity, thickening, or other 
alterations in texture, the organic disease by some- 
described under the title glaucoma, fungus, hsema- 
todes, and hydrophthahnia. To this division must 
also be referred those cases depending on wasting, 
tumour, or other disorganization of the optic 
nerve, pressure from exostosis, aneurism, or other 
tumour. The functional form of the disease ne- 
cessarily includes those cases which depend on 
affections of the brain without actual diseased 
condition of the optic nerves, derangements of the 
vascular system, irritations of the gastric or intes- 
tinal mucous surfaces, disturbed uterine functions, 
mental emotions, and general debility. Hence 
amaurosis from hemorrhage, plethora, venous tur- 
gescence, menorrhagia, amenorrhoea, diarrhcra, 
worms, dentition, hysteria, venereal indulgence, 
suppressed cutaneous eruptions, nursing, and sup- 
pressed secretion of milk. Diseases of the brain 
present difficulties in the adaptation of this ar- 
rangement. Effusion of blood or serum, tumour 
or softening, may cause amaurosis, either by the 
effect on the sensorium generally, in which case 
the disease might be considered functional ; or by 
actual pressure or destruction of the optic nerve 
in some place from its origin to its exit, in which 
case it is to be considered organic. 

If the example of some writers be followed, 
who consider amaurosis, from whatever causes it 
may arise, as presenting a certain uniformity of 
character, every symptom which has ever been 
found to occur in any form of the disease, must 
be enumerated as the symptom of that uniform 
disease. But it is obvious, that, although a cer- 
tain train of common symptoms present themselves 
in every form of the disease, amaurosis from pe 
culiar causes must afford peculiar symptoms. Tin 
symptoms common to the disease in all its varie 
ties, must first be enumerated, and those peculia; 
to each particular form detailed as such particulai 
form comes under consideration. 

Imperfection or loss of vision is, of course, the 
essential and prominent symptom of this disease ; 
that is, the principal complaint of the patient, and 
the cause of his visiting the practitioner. The 
imperfection of vision varies both in degree anil 
form. 7 lie student complains that he can no 



80 



longer read with comfort, the letters become con- 
fused, indistinct, and run into each other; the 
mechanic complains that he can no longer follow 
his employment ; the watchmaker can no longer 
detect minute flaws in his work ; the carpenter 
cannot make a correct joint ; the smith no longer 
distinguishes the thread of a fine screw or the 
head of a rivet ; and workers with the needle and 
at the loom become completely disabled from fol- 
lowing their employments. The next prominent 
symptom is the appearance of motes, films, gauze, 
cloud, or coils, intervening between the observer 
and the object, technically called muscae volitantes. 
These appearances are thus described, by Mr. Tra- 
vers, from personal experience : " The musca voli- 
tans is sometimes solitary, following the eye at a 
fixed angle as it passes along a line ; sometimes 
two, three, or more, are presented ; more frequent- 
ly an immense assemblage, descending in a cloud 
as the eye is raised, and ascending as it is depress- 
ed. They are obvious to so many analogies, and 
apprehension of impending blindness makes pa- 
tients so minute in their observation and descrip- 
tion of them, that it is scarcely possible to do jus- 
tice to our experience in attempting to describe 
them. Sometimes they are represented as globu- 
lar, sometimes angular and flat, like a piece of 
money. Portions of flue, of soot, insects' wings, 
transparent vesicles, or minute globules of quick- 
silver, connected like the links of a chain, or short 
hairs with their bulbs attached to them, are ordi- 
nary resemblances. They occupy the air with 
some persons, and are seen upon looking at the 
sky, or upon a white sheet of paper, and especially 
in shifting the eye from one object to another ; 
to some they appear in the fire or candle only, 



AMAUROSIS. 

"Tom the altered state of the function .of depart. 



and under this head you may have every kind of 
impaired vision ; every kind of defect in the per- 
ception of objects as to form, colour and their 
relations to each other: the patient who has 
amaurosis generally complains ot weakness or 
dimness of sight; he cannot employ he eye to 
long as he used to do ; the letters of a book begin 
to run into each other ; or other evidences of 
imperfect sight are noticed. In this early and 
incipient stage of the affection, where sight is 
only partially imperfect, it has been called ambly- 
opia amaurotica, amaurotic weakness of sight. 
The various defects of sight (yitia visus), enume- 
rated as distinct diseases in nosological catalogues, 
are only to be considered as amaurotic symptoms, 
forms of the impaired function. Of these may be 
mentioned, visus nebulosus, visus interrupttu, 
visus dimidiatus, visus m uscarum, or myodesopia. 
Floating bodies appearing before the eye have 
been called muscae volitantes, and when only a 
single black speck is seen, it is called scotoma. It 
is not uncommon for a patient to see a black speck 
in the centre of an object ; and as the affection 
proceeds, the opacity increases in size, becoming 
larger and larger, until it covers the field of vision. 
When these objects increase in number, they form 
before the eye a sort of gauze or network, and 
that state of vision has been called visus reticu- 
latus. Sometimes objects appear brighter than is 
natural, and that is called visus lucidus, or pho- 
topsia, and occasionally that brightness is so con- 
siderable as to produce uneasiness to the patient, 
which is then named photophobia. Isolated ob- 
jects are seen occasionally double, and hence the 
name sometimes given to amaurosis of visus 



and with others they seem to cover the ground, so duplicatus ; this, however, is gener dly the result 



that they walk in them knee-deep." [These ap- 
pearances may likewise be present when there is 
no serious affection of the eye. They are depend- 
ent upon some modification in the blood-vessels 
of the retina, which may never interfere farther 
with vision. (Dunglison's Human Physiology, 
5th ed., i. # 220: Philad. : 1844.)] The next 
symptom of amaurosis is different in its nature 
from the last : the retina appears to be insensible 
in some of its parts, while the rest retains the 
natural sensibility to light. In such case the 
patient complains of double vision, or interrupted 
vision, as if portions of objects were deficient, as 
letters or syllables in words when reading ; or of 
half vision, when one-half of an object is seen 
distinctly and the other half is totally invisible ; 
or objects are seen only when placed in a par- 
ticular position, requiring some attention on the 
part of the patient to place the object in such 
a position as will direct its image to the sen- 
sible part of the retina. Ocular spectra con- 
stitute another symptom of amaurosis ; in this 
case the images of luminous objects remain on the 
retina after the object has been removed, or the 
eye turned from it 5 as when the patient looks at 
the sun, a candle, or a patch of any bright colour, 
on turning the eyes away or even closing them, 
an image of those objects still presents itself, but 
-jf.a different colour. The symptoms complained 
of by an amaurotic patient are thus summed up 
by Mr. Lawrence, in his published lectures .- "The 
symptoms of amaurosis are such as are derived 



of strabismus. There is also a visi & coloratus 
and a visus dejiguratus, from objeel being seen 
of wrong shape and colours. In 1 articular in- 
stances, the eye affected with amaurosis becomes 
near-sighted or far-sighted, or, as it is termed, 
myopic or presbyopic ; a presbyopic state of the 
eye is the most common attendant on amaurosis; 
it is less frequent for the eye to become myopic in 
this affection. It is very common for patients to 
be able to see objects laterally after they have lost 
the power of seeing them in the direct line of 
vision." 

The symptoms above enumerated are denomi- 
nated, by Mr. Mackenzie, the subjective symptoms, 
while he applies the term objective to those now 
to be noticed ; in other words, we learn from the 
patient the defects he experiences, and from obser- 
vation those which are visible to others. The 
state of the pupil, the action of the muscles of the 
eye, the attitude or expression of the patient, are 
of the latter description. The changes in organi- 
zation obvious to the eye must be distinctly con- 
sidered when amaurosis from this cause is dis- 
cussed. 

The size of the pupil, and the degree of activity 
in the motions of the iris, often afford valuable 
information as to the extent of disease, but, per- 
haps, not to be so far relied upon as is "-enerally 
supposed. The motions of the iris, even if cor- 
rectly understood, are still the subject of dispute ; 
and the complicated distribution and connexion 
of its nerves is not satisfactorily settled • it is 



AMAUROSIS. 



81 



therefore, not surprising that the state of the pupil 
in amaurosis should often be unintelligible. It 
cannot be denied that, in the majority of cases, 
defective vision from impaired sensibility of the 
retina is accompanied by a sluggish or inactive 
state of the pupil ; and that, therefore, the state 
of the pupil must always be considered a valuable 
guide toward a correct knowledge of the cause and 
extent of the disease. In the commencement of 
the disease, the pupil dilates and contracts slug- 
gishly ; as the disease increases, the pupil becomes 
more dilated and fixed ; and in complete blindness 
it is fully and permanently dilated, constituting 
the true gufta serena. From this general rule, 
however, the practitioner finds many exceptions. 
Complete blindness is not necessarily accompanied 
by completely dilated pupil or gutta serena ; on 
the contrary, perhaps there are more cases of com- 
plete blindness with contracted or half-dilated 
pupils than with perfect dilatation. It is also to 
be remembered that complete and permanent dila- 
tation of the pupil is not necessarily accompanied 
by loss of vision : the application of belladonna 
proves that it is not; and cases of fully dilated 
pupils without blindness are occasionally met with. 
Amaurosis, both complete and partial, is some- 
times found to be accompanied by active and per- 
fect contraction and dilatation of the pupil. This 
is not the place to attempt an explanation of these 
apparent anomalies ; the subject is one of the 
greatest difficulty, and involves so many conside- 
rations foreign to the present article, that the stu- 
dent must be satisfied with the facts alone. 

The motions of the eye-ball and lids, and the 
general aspect, gesture, and bearing of the patient, 
often afford valuable information to the practi- 
tioner. Most writers have described the vacant 
expression of countenance which is often observed 
in persons completely blind from amaurosis. In 
such case the patient approaches with a moping 
stare and gesture of apprehension, as if completely 
bewildered. This is, however, often accompanied 
by other symptoms of paralysis, and is, perhaps, 
to be observed in those cases only which depend 
on cerebral disease. The gesture of the patient 
blind from cataract is different, because vision is 
not entirely gone ; he approaches in an attitude as 
if endeavouring to see something through the thick 
cloud which is interposed between hiin and ob- 
jects. The motions of the eye-ball are often 
highly characteristic. The eye is either fixed, 
with very little mobility, or it turns irregularly in 
every direction, with a trembling oscillating mo- 
tion. This occurs most frequently in bad cases 
of long standing. 

Squint is another symptom often observed in 
amaurosis. This may arise from the effort of the 
patient to bring a more sensible portion of the 
retina into the position in which it may receive 
the impression of the image of the object ; or it 
may arise from a diseased condition of the third or 
of the sixth pair of nerves. In the disease technically 
called ptosis, all the muscles supplied from the 
third pair of nerves are paralysed, and squint is 
produced by the action of the external straight 
muscle, which is supplied from the sixth pair. 
Squint is also unquestionably produced by paraly- 
sis of the external straight muscle from disease 
affecting the sixth nerve. 
Vol. I.— 11 



[The method of examining the eye, termed the 
" catoptric," which consists in holding a candle 
before the eye, the pupil of which has been pre- 
viously dilated by belladonna, and noting the images 
of the candle, affords valuable information, where 
any difficulty exists, as is at times the case, whether 
the disease be amaurosis or cataract. When the 
humours are unimpaired, and the affection is 
wholly in the nerve of vision, three images of 
the candle are seen ; two erect, and one inverted ; 
the former reflected respectively from the cornea 
and the anterior layer of the crystalline ; the latter 
from the concave surface of the crystalline; whilst 
in cataract the erect, or the inverted image, or 
both, will be dull, indistinct, or absent, owing to 
opacity of the anterior or of the posterior portion 
the crystalline, or of both.] 

The origin, causes, and symptoms of amaurosis 
having been discussed in a general way, the dis- 
ease is now to be considered circumstantially in 
detail as it depends on distinct and obvious causes. 
The most frequent cause of amaurosis of the worst 
form is internal inflammation of the eye and its 
consequences. This is, therefore, the first to be 
considered. 

1. Amaurosis from inflammation of the 

retina, and its consequences. 
That amaurosis, or, to speak more plainly, 
defective vision, must attend inflammation of the 
retina is obvious ; it is, in fact, the symptom, not 
the disease : and, therefore, the subject of inflam- 
mation of the retina must receive distinct conside- 
ration. The first question to be settled is, whether 
inflammation of the retina ever exists perfectly 
insulated, and without involving the neighbouring 
structures ; or whether inflammation of the other 
parts of the globe of the eye, as the iris or choroid, 
ever occurs without involving the retina. This 
is a question of some difficulty. The functions 
of the retina are so frequently impaired from iritis, 
both during the existence of inflammation and 
after it subsides, that the extension of the inflam- 
mation from one to the other, or their co-existence 
in both, must be admitted ; and, therefore, the 
general adoption of the term iritis, and its frequent 
application to inflammation of all the contents of 
the eye-ball, have proved most injurious, by direct- 
ing the attention of the practitioner to the state 
of the iris exclusively, and placing out of view the 
retina, which, from its greater delicacy, and from 
its integrity being so much more essential to 
vision, should be an object of greater anxiety. It 
is not denied that iritis does occur without corre- 
sponding inflammation of the retina; but it is 
certain that they are both frequently engaged, and 
that the disease, in such cases, is general inflam- 
mation of the eye-ball, or internal ophthalmia. 

Mr. Travers says, in his Synopsis of Diseases 
of the Eye, page 137, that "the retina is some- 
times, though rarely, the seat of inflammation ; 
but it is a* error to suppose that intolerance of 
light is a sign of this affection, as is clearly proved 
in the strumous ophthalmia, in which, though the 
intolerance is in excess, the retina is uninjuied : 
and, secondly, because the effect of inflammation 
upon a nerve of sense is to produce palsy, not 
increased excitability." That intolerance of liglit 
is not necessarily a symptom of inflamed retina 
may be admitted ; but it is net Droved that lh*> 



82 



effect of inflammation is to produce palsy of a 
nerve of sense. 

The causes of inflammation of the retina are as 
various as those of general inflammation of the 
eye-hall. The disease may arise from gout, 
rheumatism, syphilis, mercury, or typhus fever ; 
or it may be idiopathic, without assignable cause. 
Mr. Laurence appears to consider every form of 
amaurosis to arise from inflammation. He says, 
'•Amaurosis, in its most frequent and important 
form, that which is seated in the eye itself, is 
generally inflammation of the nervous structure; 
including, under that phrase, all d-egrees of in- 
creased vascular activity, whether designated as 
fulness, turgescence, determination, congestion, or 
as inflammation in its most limited sense ; and 
the usual result of inflammatory disturbance, that 
is, organic change, permanently destroying the 
function of the part." 

Mr. Travers describes the symptoms of inflam- 
mation of the retina as follows : « the first and 
predominant symptom of inflamed retina, viz. a 
sudden attack of vehement dashing pain of the 
most distracting kind, which is described to extend 
from the bottom of the eye-ball to the occiput, or 
in the reverse direction, and the supervention 
within a few hours of total blindness, with occa- 
sional sparks and flashes of vivid light." '• The 
pupil, upon inspection, is gaping and motionless, 
as in confirmed amaurosis, and the humours are 
thick and muddy." Mr. Wardrop observes, that, 
" When the retina is affected with inflammation, 
the disease is marked by painful vision; intole- 
rance of light; sparks of fire, or drops of a red 
colour falling before the eyes ; little external red- 
ness ; pain darting through the head ; with more 
or less constitutional derangement." To suppose 
that inflammation of the retina is always accom- 
panied by those violent symptoms would be dan- 
gerous in practice. The disease is often mild and 
insidious in its approaches, and marked more by 
defective vision than by symptoms of inflamma- 
tion. The first care of a practitioner, on approach- 
ing a person complaining of defective vision of 
recent occurrence, is, to ascertain whether there 
be any evidence of the existence of inflammatory 
action in the retina. The symptoms may often 
fail to satisfy him ; there may be no pain, no 
morbid sensibility to light, no headach. The 
state of the pupil is no guide, as it is affected, more 
or less, in almost every form of amaurosis. The 
form or nature of the spectra, or m it sex vol! f an- 
tes, does not enable him to pronounce with cer- 
tainty. The difficulty is, however, frequently 
removed by careful inspection of the state of the 
sclerotic coat. The arterial inflammatory vascu- 
larity of the sclerotic has always afforded a charac- 
teristic symptom of internal inflammation of the 
eye-ball, and has been dwelt upon with emphasis 
by Mr. Saunders, and subsequent writers. The 
red vessels converging toward the anterior part of 
the eye-ball, in distinct lines, and forming by their 
delicate subdivision into minute branches a bright 
red zone round the circumference of the cornea, 
is always pointed out to the student as an appear- 
ance indicative of internal inflammation, and a 
uniform accompaniment of iritis. This appear- 
ance often, perhaps always, in a greater or less 
degree, accompanies inflammation of the retina ; 



AMAUROSIS 

"~Ind when attended by defective vision and com 



plaint of a film or gauze before the eye, should 
probably be considered conclusive evidence ol the 
nature of the disease. 

The treatment of inflammation ol the retina 
must embrace the means usually adopted to re- 
move or restrain inflammatory action, modified 
and proportioned to the nature, peculiarity, and 
intensity of the disease in each individual case. 
Such are, general bleeding, leeching, and cupping, 
nauseating and purgative medicines, mercury, and 
blisters. When the attack is accompanied by the 
intense and alarming symptoms just now enume- 
rated, on the authority of Mr. Travers, the adop- 
tion of a vigorous plan of depletion is obviously 
demanded, and general and local bleeding indi- 
cated ; recollecting, however, that we should not 
be too sanguine as to the result, or place too 
much confidence in these resources, unassisted by 
other means. Daily experience proves how un- 
availing mere depletion is found in irritis, or gene- 
ral internal inflammation, and even how unsuited 
to particular cases, however intense the symptoms. 
The value of mercury in the treatment of inter- 
nal inflammation of the eye in general, and of in- 
flammation of the iris in particular, is now so fully 
appreciated, that no argument need be employed 
to induce the practitioner to give it a fair conside- 
ration. Mr. Travers makes the following ob- 
servations respecting its administration : " When 
the amaurosis is recent and sudden, and either 
the signs of an obscure inflammation are present, 
or only the amplitude and inactivity of the pupil 
correspond to the patient's history, the indication 
is less simple ; mercury should be introduced with 
all convenient rapidity into the system, I mean so 
as to ruffle in the least possible degree. No ad- 
tage is obtained by salivation ; on the contrary, I 
think it hurtful. When mercury is beneficial, its 
efficacy is perceived as soon as the mouth is sore. 
I have seen it tried, and have myself tried it in 
many cases of amaurosis, without the smallest ad- 
vantage ; but in cases of recent occurrence, im- 
perfect, but rapidly progressive from bad to worse, 
I have been witness to its power in suddenly ar- 
resting the disease in too many instances not to 
entertain a far higher opinion of it than of any 
other article of the Materia Medica." Mr. Law- 
rence, who, we have already said, appears to con- 
sider the majority of cases of amaurosis to arise 
from inflammatory action, sums up the treatment 
as follows : " Our object is to put a stop to vascu- 
lar excitement, to prevent the permanent injury 
of altered structure, and impaired function in a 
structure the peculiar delicacy of which particu- 
larly exposes it to such danger. We must, there- 
fore, employ antiphlogistic treatment of a decided 
character, and follow it up with a decision and 
steadiness commensurate with the importance of 
the affected organ : under the head of antiphlo- 
gistic treatment, must be included general and 
local blood-letting, but more particularly the latter, 
as, by cupping from the back of the neck or the 
temples, or by the application of leeches, the eva- 
cuation of the bowels by purgatives, and a re- 
stricted diet. Repose of the organ should be ob- 
served, more or less complete, according to the 
nature of the case ; counter-irritation by blieten, 
from which a discharge may be kept up by irri- 



AMAUROSIS. 



83 



tating dressing : these are the means suitable to 
the early stage of the affection, the stage of ex- 
citement ; but if this treatment be not found to 
remove the change which has been produced in 
the retina, we must have recourse to mercury, 
which appears to be as decidedly beneficial in these 
cases, as in iritis, or general internal inflamma- 
tion. The remark which I made respecting the 
use of mercury in those affections, applies also to 
the present case, namely, that its good effect 
mainly depends on the promptitude with which 
it is employed. The alterative form is insuffi- 
cient ; we give it with the view of arresting in- 
flammation in the structure, which is the very 
seat of vision : that structure is easily changed by 
the inflammatory process ; our only remedy is to 
push the mercury in a decided manner ; and, if 
we do so, we shall put a stop to the affection. 
We have used mercury very freely for amaurosis ; 
we have used it until profuse salivation has been 
produced, and many decided instances of the good 
effect of this practice have come under our ob- 
servation." 

The practitioner has other resources than those 
above mentioned. Internal inflammation of the 
eye yields often to remedies of very different cha- 
racter ; and inflammation of the retina forms part 
of that disease. Cases may occur where general 
depletion is inadmissible. Old and debilitated 
females, scrofulous subjects, persons already weak- 
ened by disease, poverty, or confinement in ill- 
ventilated apartments, or who have, perhaps, just 
gone through a mercurial course, evidently would 
not derive relief from such treatment : on the con- 
trary, they would require a tonic plan of treatment, 
with the free administration of bark and generous 
diet. If inflammation of the iris be arrested or 
restrained by the administration of turpentine, as 
stated by Mr. Hugh Carmichael, and it seems 
agreed that in certain cases, probably of peculiar 
character, it is a valuable remedy, it should con- 
stitute one of the resources in inflamed retina. 
Should the inflammation occur in a gouty or 
rheumatic habit, or alternate with affections of the 
joints, or other symptoms of these diseases, the 
treatment must be modified accordingly, and ad- 
vantage taken of the resources which medicine 
affords in such cases. Colchicum, under such 
circumstances, has been resorted to with some 
advantage. The eye should be protected from 
the irritation of strong light ; but total darkness is 
unnecessary, and is probably pernicious, by in- 
creasing the sensibility of the retina. Care should 
be taken that, in excluding light, the free circula- 
tion of fresh air round the patient should not be 
interrupted. No circumstance has contributed 
more to the want of success in cases of this de- 
scription, than confinement of the patient to the 
respiration of an atmosphere contaminated by 
human effluvia. 

2. Amaurosis from disorganization of the 
retina, a consequence of inflammation. 

It is reasonable to believe, that during the in- 
flammation of the retina, vision is impaired by 
those changes which uniformly accompany in- 
flammation, as increased vascularity, and excited 
or altered sensibility ; while the effects or conse- 
quences, such as enlargement of vessels, and 
thickening or disorganization of structure, remain 



after inflammatory action has subsided. These 
two states present as remarkable a difference in 
character as the acutely inflamed conjunctiva, and 
the vascular and altered condition heretofore de- 
nominated the chronic stage of that disease. In 
practice this distinction must never be lost sight 
of, because the treatment of an inflamed retina 
must be very different from that of a retina which 
has formerly suffered from inflammation. The 
practitioner, therefore, has first to ascertain whe- 
ther the case before him be actual existing inflam- 
mation of the retina, or disorganization produced 
by inflammation. 

Cases of amaurosis from disorganization of the 
retina are of frequent occurrence, because this 
state of the eye is produced by every form of in- 
ternal inflammation. The patient complains of 
defective vision, under all circumstances : he can 
read with difficulty, for he can only distinguish 
the larger letters ; he sees the general outline of 
objects, or the more remarkable appearances in 
form or colour, but he cannot distinguish the fea- 
tures of those near him, or recognise his acquaint- 
ances. A film or mote of precise unvarying form 
appears to float before the eye, and frequently a 
uniform cloud or mist interrupts vision. A lighted 
candle appears as if seen through a mist, or is 
surrounded by a halo. These are a few of the 
symptoms of which the patient complains : many 
others of the same description are occasionally ob- 
served. 

On looking into the eye in such cases, the 
pupil may appear perfectly transparent ; the iris 
may be capable of acting, though sluggishly ; and 
the cornea and sclerotic may be in an apparently 
healthy state. On a closer inspection, a slight 
irregularity of the pupil may be observed, which 
becomes more remarkable upon shading the eye 
from the light, and still more upon dilating the 
pupil with belladonna, when an adhesion of the 
margin of the pupil to the capsule of the lens at 
one or two points becomes visible. 

Where this little brown string of adhesion is 
attached to the capsule, a slight opacity of that 
part may be observed. This is the slightest de- 
gree of actual change of structure to be observed 
in those cases ; in other examples the disorganiza- 
tion is much more obvious. If the eye has suf- 
fered from severe internal inflammation, the entire 
margin of the contracted pupil adheres ; causing a 
circle of white opacity at the place of adhesion, 
and leaving a central portion of the capsule and 
lens transparent, and capable of transmitting the 
rays of light to the retina. If the previous in- 
flammation has been still more destructive in its 
consequences, the pupil is much contracted, or 
even completely closed, and adhering to the cap- 
sule of the lens, which is opaque ; constituting 
capsular and, probably, lenticular cataract. The 
existence of the cataract does not alter the case as 
regards the retina ; it is still, partially or wholly, 
insensible to light, as is often proved by the want 
of success in operations for cataract in such cases ; 
and this very state of the eye should make the 
operator cautious in his prognosis as to the result 
of an operation, as in such cases the cataract may 
be removed, and yet no vision follow, on account 
of the disorganization of the retina. The sclerotic 
coat frequently presents, in such cases, a livid 



84 



AMAUROSIS. 



vascularity, willi large veins ramifying through it 
in every direction ; and in the worst cases the 
shape of the globe is altered, and the sclerotic is 
projected or stretched into a staphylomatous tu- 
mour, or depressed into hollows by the action of 
the muscles. This state of eye-ball is highly cha- 
racteristic of the completely unsound retina, and 
proves the hopeless nature of the disease. 

In considering the treatment of amaurosis, or 
impaired vision, the consequence of internal in- 
flammation, the first question to be determined is, 
whether the treatment adopted in the inflamma- 
tory stage be applicable to this : recollecting that 
the state of the eye now under consideration is a 
consequence observed many months, or even years, 
after the cause has subsided. The doubts re- 
specting the state of the retina, and the treatment 
of its diseases, arise from the impossibility of see- 
ing the alterations in its structure. Opacities of 
the cornea, and enlarged vessels of the conjunc- 
tiva, are visible after the inflammatory stage of 
purulent ophthalmia has passed away ; and the 
practitioner is, therefore, satisfied that he cannot 
remove them by a repetition of the depletion 
which he first adopted. If the thickness and vas- 
cularity, which probably exist in the retina, were 
equally visible, he would also despair of removing 
them by his first plan of treatment. Abstraction 
of blood may be advantageous in full plethoric 
habits, to relieve a turgid state of vessels already 
permanently enlarged ; but it should not be re- 
sorted to with the view of removing inflammatory 
action, which no longer exists. Mercury is fre- 
quently administered in these cases, and appa- 
rently because it has been found advantageous in 
the inflammatory stage. If mercury be of any 
use in such cases, it is by promoting absorption 
of lymph or other deposit found during inflam- 
mation ; it is not, however, found to effect such 
objects ii: ciscs where deposits, or thickenings, 
are obvious to the eye, as in opacities of the cor- 
nea, or in closed pupil, and, therefore, probably 
possesses no such power here. At all events, 
mercury should not be indiscriminately resorted 
to, and a guarded prognosis of the result of its 
administration should be made. To rouse the 
activity of the impaired function, or to raise the 
sensibility blunted by disorganization, impressions 
on the extremities of the fifth pair of nerves may 
be advantageously resorted to ; hence the practice 
of repeated blistering all round the orbit, or of 
applying stimulating liniments, or sinapisms, in 
the same situation. With the same view, ster- 
nutatories may assist ; and perhaps, in certain 
cases, electricity. 

3. Amaurosis prom vascular turges- 
cence, not amounting to inflammation. 

Amaurosis is sometimes caused by hemorrhage, 
as will as by a general plethoric state of the vas- 
cular system ; but it is difficult to determine why 
this happens in some cases only. Hemorrhage 
occurs every day. and yet blindness from this 
cause is rare. Amaurosis is not by any means a 
constant, perhaps not a frequent symptom of gen- 
eral plethora, or that state termed a determina- 
tion of blood to the head. Whatever mav be the 
condition of the arterial capillaries of the retina 
when the action of the heart is suspended, inter- 
rupted, or greatly weakened, blindness is not a 



necessary consequence ; it docs not occur in Weed- 
in.,, unless faintness be produced , it docs not at- 
tend extreme weakness, with imperceptible pulse, 
preceding death; nor is it a consequence of the 
application of a ligature on the carotid, which re- 
strains hemorrhage or cures aneurism. On the 
other hand, whatever may be the state of the ve- 
nous capillaries of the retina, during a turgid or 
obstructed state of the venous circulation, blind- 
ness is not found to be a consequence of tempo- 
rary pressure of the jugular veins, or of accumu- 
lation of blood in the right side of the heart, from 
disease of the heart or lungs. These considera- 
tions are important in a practical point of view; 
upon them the practitioner founds his estimation 
of the degree of value of a system of depletion, 
or the opposite plan of invigorating or increasing 
the activity of the vascular system. 

The first care of the practitioner in cases of de- 
fective vision, without apparent inflammation or 
disorganization of the retina, is to ascertain, as far 
as symptoms admit, whether there be reason to 
suspect increased arterial or obstructed venous vas- 
cularity. The amaurotic symptoms afford no sa- 
tisfactory evidence upon the subject. The informa- 
tion must be derived from the appearance of the 
patient, or the existence of undue vascular action 
elsewhere, turgidity of the vessels on the surface, 
especially those visible in the conjunctiva or scle- 
rotic, throbbing of the arteries of the head, or ful- 
ness of the jugular veins. Mr. Mackenzie, in his 
Treatise on the Diseases of the Eye, says, « It 
has been mentioned that plethoric persons are in 
general able to produce a degree of congestive 
amaurosis at will, by stooping, tying their neck- 
cloth tight, and the like. We also frequently wit- 
ness a temporary amaurosis from exhaustion. For 
instance, if the nervous system is the seat of no 
particular excitement at the time, we observe that 
by the sudden abstraction of blood, the organs of 
vision, and, indeed, all the organs of sense, are 
strikingly enfeebled. In some individuals the de- 
bility continues for several days, and if any one 
of the organs of sense has been previously weaker 
than the rest, the feebleness of that organ is gene- 
rally increased by bloodletting. When syncope 
is produced by loss of blood, sight appears to be 
the sense which fails first, and which recovers last. 
Hearing is next, while smell, taste, and touch, are 
less affected, and more easily re-animated by exci- 
tation. They return in a very short time to their 
natural state \ but it is not so with sight. It is a 
popular opinion that bloodletting weakens the 
sight, and, to a certain length, the opinion is 
founded in fact." This view may be contrasted 
with that in the preceding paragraphs; but what- 
ever doubt may be entertained respecting the effect 
of particular states of the vascular system on 
vision, there can be none in practice as to the pro- 
priety of removing, if possible, a turgid state of 
the vessels, in persons suffering from amaurosis. 

If, therefore, a person complains of defective 
vision, with those symptoms which indicate vas- 
cular turgcscencc, the cause of this turgescence 
must, if possible, be ascertained. If the counte- 
nance is bloated and purple, and the conjunctiva 
full of large veins, and there are difficult respira- 
tion and other symptoms of disease of the heart 
or lungs, the cause is obvious. Such cases are of 



AMAUROSIS. 



83 



daily occurrence, and in the indications of treat- 
ment the removal of that cause must not be over- 
looked ; or, if it cannot be removed, the prognosis 
must be regulated accordingly. But if no such 
existing disease be obvious, and yet defective vision 
with symptoms of vascular turgescence be present, 
that symptom must be combated by the usual 
means ; as bloodletting local and general ; blisters 
or sinapisms behind the ears as counter-irritants, 
or a seton in the neck, as a permanent discharge ; 
sponging the forehead and head with cold water, 
using the shower-bath. The bowels should of 
course be emptied, and all future accumulation 
there prevented, and the functions of the stomach 
and liver preserved in a state of perfection. Ab- 
stemious diet, exercise in the open air, alterations 
in habits, and every other plan calculated to im- 
prove the general health, should of course be en- 
joined. In the application of this plan of treat- 
ment, the following observations of Mr. Travers 
deserve attention : " A loss of balance in the 
sanguiferous system, occasioning an undue deter- 
mination of blood to the head, often exists distinct 
from general plethora, and is aggravated by loss 
of blood. Cases of undue determination of blood 
to the organ are especially common after deep- 
seated chronic inflammation, or distress from over 
excitement, by which vessels have lost their tone ; 
an effect decidedly increased by depletion." 

4. Amaurosis from interruption of the 
functions of the digestive organs. 

Whatever doubts may be entertained respecting 
the efficacy of the treatment of amaurosis by eme- 
tics and purgatives, it appears to be agreed on all 
hands that defective vision is often a consequence 
of interruption of the functions of the digestive 
organs. That amaurosis is, however, every day 
attributed to this morbid condition where there is 
no evidence of the existence of any such cause, 
is known to every practitioner ; but it is equally 
notorious that it is frequently a symptom of dys- 
pepsia, and its occurrence from worms or other 
irritating matters in the alimentary canal is a still 
more decisive proof of the effect of such causes. 
It must not be forgotten, that in the majority of 
these cases the individual is exposed to those 
remote causes which may lead to the interruption 
of the functions of the retina as well as those of 
the alimentary canal. The sufferers are generally 
artisans or students, whose gastric organs may be 
injured by their sedentary habits, mental exertions, 
or confinement in close and unhealthy apartments; 
while vision may at the same time be impaired by 
the application of the eye to minute or brilliant 
objects. For practical purposes, it is only neces- 
sary to determine whether a patient complaining 
of impaired vision, and muscse volitantes, with 
sluggishly acting or fixed pupil, foul tongue, head- 
ach, flatulence or acidity of the stomach, and tor- 
pid bowels, should be treated for his dyspeptic 
symptoms, or only for the amaurosis ; and, on the 
other hand, whether a patient complaining of im- 
paired vision, muscse volitantes or spectra, and 
presenting a fixed or inactive pupil, without any 
apparent symptom of gastric disease, should be 
treated with medicine calculated to remove dyspep- 
sia. Whatever doubt may be entertained respect- 
ing the propriety of the administration of emetics 
and purgatives in amaurosis, where the state of 



the digestive organs does not indicate it, there 
cannot reasonably be any in directing the atten- 
tion to this object where defective vision is accom- 
panied by gastric derangement. 

Schmucker and Itichter in Germany, and Scar- 
pa in Italy, have been the most decided advocates 
for the emetic practice ; and in this country it has 
been followed up with various degrees of success : 
upon the whole, however, the testimony of writers 
is unfavourable to the practice, at least unless in- 
dicated by symptoms of gastric or biliary derange- 
ment. The following is the plan adopted by 
Scarpa : " The first part of the treatment of im- 
perfect amaurosis is restricted to emetics and in- 
ternal resolvents. It is desirable in the majority 
of cases, if the patient is an adult, to prescribe 
three grains of tartar emetic dissolved in four 
ounces of water, of which he should take two 
spoonfulls every half hour until nausea and abun- 
dant vomiting be produced. The day after, he 
should take the resolvent powders, composed of an 
ounce of cream of tartar, and a grain of tartar 
emetic, divided into six equal parts. The patient 
should take one in the morning, another four hours 
after, and a third in the evening, for eight or ten 
days in succession. This remedy will cause some 
nausea, and produce some more frequent discharge 
of the bowels, and perhaps some vomiting. If 
during the employment of these resolvent pow- 
ders the patient makes ineffectual efforts to vomit, 
if there is a bitter taste in the mouth with loss of 
appetite, without any improvement in vision, the 
emetic should be repeated ; and this for three or 
four times, if the presence of gastric irritation, 
bitter taste in the mouth, tension of the hypochon- 
dria, acid eructations, and tendency to vomit de- 
mand it. When the stomach is cleared out, the 
resolvent powders of Schmucker should be pre- 
scribed, consisting of the following ingredients : 
Gum. sagapen., Galban. Sap. venet. aa. gi ; Rhei. 
giss ; Antim. et Potass. Tart. gr. xvi. Ext. gly- 
cyrr. ^i ; Ft. pil. gran, unius. Fifteen of those 
pills to be taken night and morning for four or six 
weeks; or the formula of Richter, consisting of 
the following ingredients, may be preferred : Am- 
moniac. Assafoetid. Sap. Venet. Valerianae rad. 
Summit, arnicas aa. gii ; Antim. et Potass. Tart. 
gr. xviii. ft. pil. gr. 2. Fifteen to be taken three 
times a day for some weeks." It is scarcely ne- 
cessary to observe that the farrago composing these 
resolvent pills can possess no peculiar virtue, and 
that modern improvements place more valuable 
remedies and resources in the hands of the prac- 
titioner. Nor need we repeat here the plans of 
treatment to be adopted for the removal of the dis- 
eased condition of the stomach or alimentary canal 
The educated practitioner must suit his treatment 
to the peculiarities of each particular case ; keep- 
ing in view the necessity of removing all offend- 
ing matters from the stomach and bowels, avoiding 
all food or drink calculated to aggravate the dis- 
ease, and altering as far as possible the habits of 
the patient. 

It is desirable to record the opinions of practical 
writers respecting the treatment just alluded to. 
Mr. Travers, p. 304, says, " I do not recollect an 
instance of decided benefit from the emetic prac- 
tice, although, in respect to its high authority. I 
have tried it fairly in many instances. The cases 



<6 



AMAUROSIS. 



of gastric disorder to which it is especially appli- 
cable, arc most benefited by a long course of blue 
pill, with gentle saline purgatives and tonic bit- 
ters. In most of those cases we must depend, 
first, on the regulation of the visceral functions; 
and, secondly, on the employment of such resto- 
ratives as the system requires and can bear. The 
blue pill, with colocynth, rhubarb, or aloes, and 
the combination of soda with rhubarb and Colombo 
or gentian, are best adapted to the former purpose. 
The exhibition of general tonics is often strongly 
indicated, and I have seen much benefit derived 
from the mineral acids, bark, steel, (when admissi- 
ble,) and arsenic, after a due regulation of the 
digestive functions. I know of no article of the 
class of stimulants that has any direct claim to 
notice, or any approach to a specific virtue, such 
as has been ascribed to the arnica montana, aco- 
nite, &c." Mr. Lawrence, who, as has been 
already observed, considers the majority of cases 
of amaurosis to depend on inflammatory action, 
or vascular turgescence, observes, " When the 
antiphlogistic treatment and a fair trial of mercury 
have failed, I do not know that it is possible to 
effect any further essential good by other means. 
We must be contented with such management 
and simple diet as are most conducive to general 
health, and take the chance of such local amend- 
ment as the affected organ may slowly experience 
under gradual general improvement. Residence 
in a pure air, frequent exercise out of doors, a 
plain, mild, but nutritious diet, the regular use of 
mild aperients, with the occasional employment of 
a more active purgative, and repose of the affected 
organ, form a combination of measures best calcu- 
lated to invigorate the system generally, and thus, 
as far as circumstances will admit, to arrest local 
disease. The effects of counter-irritation may be 
advantageously tried in conjunction with such 
measures. Blisters may be applied behind the 
ears, and at the side or back of the neck, and a 
discharge may be kept up by the savin cerate. 
But we prefer a succession of blisters, applying a 
new one to a fresh surface every five, six, or seven 
days." 

[The endcrmic use of strychnia has been advised 
by Mr. Middlemore, {Treatise on Diseases of the 
Ei/e, p. 290.) and by Messrs. Liston, Henderson, 
Furnari, Petrequin and others; but Mr. Tyrrel 
and Mr. Lawrence, {On Diseases of the Eye, 
Amer. edit, p. 519,) have never seen it or veratria 
exert any power over the disease. It has been 
used, also, internally, and in the form of collyrium, 
containing from two to eight grains to two ounces 
jf water ; a little acetic acid being added to render 
the strychnia more soluble ; and two drops being let 
fall into the eye a few times a day. (Dunglison's 
New Remedies, 4th edition, p. 554, Philadelphia. 
1843.) 

Besides blisters, acupuncture, moxas, ammonia- 
ted lotions, and every form of revcllent, have been 
used to the temples, behind the ears, or to the 
back of the neck. Some cases of imperfect amau- 
rosis have likewise been treated with success by 
galvano-puncture ; and similar results have been 
obtained from the use of a galvanic current, made 
to pass from the mastoid process to the superci- 
liary ridge, {Op. c!t., p. 40 and p. 327.)] 



5. Amaurosis from exeiu-isf, of the etb 
(iv minute objects. 

It cannot be denied that defective vision is 
occasionally produced by exposure to this cause; 
but when it is recollected that thousands, nay 
millions, are thus exposed, in a greater or less 
degree, some doubt may be permitted as to its 
operation, especially when sufferers in this way 
are exposed to other causes which affect the health 
generally. Students, scriveners, printers, engra- 
vers, microscopic observers, watchmakers, gilders, 
furnace-workers, and cooks, arc enumerated among 
the sufferers from this cause. But there are seden- 
tarv or unhealthy employments calculated to im- 
pair the functions of many organs, and in this 
way alone to produce that state of the retina 
which accompanies the disease. Simply using 
the eyes constantly in intently viewing minute 
objects, although such objects should not reflect 
any unusual quantity of light, appears to impair 
vision as much as working on brilliant objects , 
at least we find as many cases of impaired vision 
among tailors, scriveners, shoe-makers, and cabi- 
net-makers, as among engravers, gilders, glass- 
blowers, or cooks. The question which it is here 
important to solve, is, what is the state of the 
retina in these cases ? Is it a state of excitement 
with morbid sensibility and increased vascular 
action, a state approaching to inflammation ? or 
is it the very reverse, a state of impaired sensi- 
bility and defective vitality r L T ntil these questions 
are solved, impaired vision, from these causes, 
cannot be positively referred to the division of 
functional amaurosis more correctly than to the 
organic. It has already been stated that Mr. 
Lawrence considers amaurosis of this character 
to depend upon inflammatory action, or, " vas- 
cular activity, whether designated as fulness, 
turgescence, determination, congestion, or as in- 
flammation in its most limited sense." 

The symptoms, in cases of this description, are 
merely impaired vision, disabling the patient from 
following the usual pursuits of reading or work- 
ing ; muscae volitantes, or spectra, of various 
colours, forms, and qualities, floating before the 
eyes : and a fixed or sluggishly acting pupil. It 
does not appear that the symptoms are materially 
different, whether the disease has arisen from 
exercise of the eye on brilliant objects, or on 
objects merely minute. 

Whether it may be advisable to rely upon a 
treatment directed to the improvement of the func- 
tions of the digestive organs in amaurosis, from 
these causes, must be very questionable. The 
principal reliance must be placed in the removal 
of the original remote cause. The patient should 
understand that no remedies can avail while he 
continues to exercise the eye as before. There 
can seldom be much difficulty in accomplishing 
these objects, when the patient docs not depend 
for a livelihood upon the exercise of his eye; but 
the poor artisan has often only the alternative 
between starvation and blindness. Under such 
circumstances, every argument should be used to 
induce the patient to give up his trade for a sum- 
mer, and to endeavour to earn his bread by rural 
occupations. The most careful inquiry and ex- 
amination must be made to ascertain whether 



AMAUROSIS. 



87 



there be any evidence of the existence of inflam- 
matory action or vascular turgescence in the 
retina. The history and progress of the case, the 
appearance of the sclerotic and pupil, the consti- 
tution and habits of the patient, must be the best 
guides. The practitioner could not reasonably 
determine to adopt an antiphlogistic treatment 
with a sallow, pallid, emaciated patient, whose 
eyes present no unusual vascularity ; while it 
might be imperiously demanded in a bloated, gross 
man of intemperate habits, and whose eyes are 
disfigured by vascularity. If it be necessary to 
adopt the antiphlogistic plan, it is to be followed 
up as detailed when speaking of inflammation of 
the retina, and recourse had to the administration 
of mercury to the same extent. If the digestive 
organs are impaired in function, they must be im- 
proved by the usual means. If there is no evi- 
dence of inflammatory action, but, on the con- 
trary, a languid circulation and general debility, 
every method calculated to improve the general 
health must be adopted, as pure air, invigorating 
diet, and tonic medicines. Blistering and other 
stimulating applications in the vicinity of the 
orbit, and pungent applications to the nostrils, 
and even to the conjunctiva itself, may be found 
of service. 

6. Amaurosis from injury or disease of 
tub fifth nerve, or its branches. 

It has long been known that injury of the 
frontal nerve, or branch of the ophthalmic branch 
of the fifth, is injurious to vision, and, conse- 
quently, that this nerve exerts some very im- 
portant influence on this function. Little more 
than this is now known, notwithstanding the 
attempts of Magendie to clear up the doubts on 
the subject by experiments on animals. These 
experiments, which are detailed in his journal of 
physiology, are of so violent and destructive a 
nature, and so much calculated to disturb or 
destroy the functions of the nervous system gen- 
erally, that the results stated to have followed can- 
not be attributed to the mere division of the fifth 
nerve. It is, however, most probable, since vision 
is impaired by injury of a branch of the fifth 
nerve, that it should also be impaired or destroyed 
by division of its trunk. Pathological observa- 
tions, hitherto not numerous or authentic, will 
probably do much more toward elucidating this 
subject than destructive experiments on living 
animals. No opportunity should be lost of as- 
certaining the state of vision previous to death, 
in persons whose fifth nerve shall be found dis- 
eased or destroyed. The nature of the connexion 
between the fifth nerve and the nerve of vision is 
illustrated by the fact, that, in cases of conjunc- 
tival inflammation, modified by scrofula, violent 
sneezing is produced by exposure of the eye to 
light. Disease or growth of a tooth has some- 
times been found to impair vision. Such a case 
is recorded by Dr. Galenzouski, of Wilna, in the 
Archives Generates, where blindness was pro- 
duced by a splinter of wood becoming entangled 
in a diseased tooth. Mr. Travers, says, " I have 
seen an incipient amaurosis distinctly arrested by 
the extraction of a diseased tooth, when the delay 
of a similar operation had occasioned gutta serena, 
on the opposite side, two years before.'' Defec- 
tive vision frequently attends neuralgia in the 



vicinity of the eye. Mr. Travers, says, "There 
is an intermittent spasmodic pain accompanying 
some cases of amaurosis, shooting through the 
orbit into the head, of the most acute and dis- 
tressing severity ; it makes a periodic attack at or 
about the same hour every night, and continues 
for several hours ; it is accompanied by convul- 
sive quivering of the muscles of the eye and eye- 
lids, and profuse lacrymation ; there is nothing in 
the appearance of the organ to explain its nature 
and origin. What has been described as an in- 
termitting ophthalmia, is, I think, improperly so 
termed — the pain, not the inflammation, is inter- 
mitting. The pain of tooth-ach, according to the 
state of the vascular system, is subject to inter- 
missions more or less complete ; but the periodic 
pain to which I refer, is independent of any visi- 
ble sign of inflammation. I believe it is a tic 
douloureux, affecting one or more of the orbitar 
branches of the fifth pair of nerves. I have cured 
it, in two cases, by arsenic, where opium failed to 
prevent the paroxysm. I have known one in- 
stance, of a similar affection, without any defect 
of vision." Mr. Wardrop affords the following 
information on this subject : " Wounds of the 
eye-brow, injuring the frontal nerve, have fre- 
quently been known to produce amaurosis ; the 
amaurotic symptoms coming on in some cases 
instantaneously, and sometimes long after the 
wound has been healed." Morgagni mentions 
having seen a case of amaurosis produced by a 
wound above the eye-brow, which, he observes, 
explains a passage of Hippocrates. « The sight," 
says the father of medicine, " is obscured in 
wounds which are inflicted on the eye-brow, or a 
little higher." This curious fact we have seen 
illustrated in several instances; and it is an example 
of the sympathy which exists between parts whose 
nerves have a direct communication, the ophthal- 
mic branch of the fifth pair sending off the fron- 
tal nerve, and also a twig to join the third pair to 
form the lenticular ganglion. It is only when the 
frontal nerve is wounded or injured, and not 
divided, that amaurosis takes place ; for, as will 
hereafter be observed, amaurosis, following a 
wound of this nerve, may sometimes be cured by 
making a complete division of the trunk nearest 
its origin. Portal saw a child, who received a 
slight puncture on the forehead with the point of 
a knife, which was followed by a considerable con- 
vulsion of the upper lid. This ceased when a 
small incision was made at the place of the punc- 
ture. A gentleman received an oblique cut in the 
forehead, which, from its direction and depth, 
must have injured the frontal nerve. The wound 
was not accompanied by any severe symptoms, 
and soon healed. But afterwards the vision of 
this eye began to fail, and in a few months was 
completely destroyed ; the pupil was much dilated, 
the iris was not influenced by variations of light, 
and had slight tremulous motions. A sailor got 
a blow on the edge of the orbit, from a ramrod 
during an engagement, at the place where the 
frontal nerve passes on the brow. The vision of 
that eye was instantly destroyed, and when we 
saw him several years after the accident, the eye 
remained amaurotic, with a dilated and immovable, 
pupil : a cataract had formed in the other eye. 
An officer, at the siege of Badajos. received h 



88 



deep wound on the eye- brow by a piece of a shell, 
which, from its direction, must have injured the 
frontal nerve. Great inflammation and pain suc- 
ceeded the wound, the vision of the eye became 
gradually imperfect, and, after a few months, was 
entirely lost. The pupil was very much dilated 
and immovable, and the crystalline lens opaque. 
Wounds of the infraorbitary nerve and purtio 
dura are sometimes followed by amaurotic symp- 
toms. Beer mentions an instance of the former ; 
and we witnessed the case of an officer, in whom 
a ball wounded some branches of the latter nerve, 
which was followed by amaurosis. This con- 
nexion between the branches of the fifth pair of 
nerves and retina affords a useful channel for ap- 
plying remedies in diseases of retina. It is not 
injury of the fifth pair of nerves alone that proves 
injurious to vision ; paralysis of the upper lid, 
with loss of power of moving the eye-ball, except 
ou'ward, evidently depending on compression or 
disease of the third pair, is also attended by defec- 
tive vision. The writer of this has very recently 
seen a well-marked case of amaurosis with dis- 
tinct and undoubted paralysis of the abductor 
muscle, disabling the patient from turning the eye 
outward, and obviously depending upon compres- 
sion or disease of the sixth pair of nerves. 

To cure amaurosis from injury of the frontal 
nerve, or any other branch of the fifth pair, is 
difficult, and often not to be accomplished. Divi- 
sion of the nerve appears an obvious resource, and 
has been repeatedly tried, but with little success : 
which, perhaps, might have been anticipated, when 
it had been observed that amaurosis had sometimes 
arisen from simple division, as in the removal of 
a tumor. Mr. Guthrie, says, " The only hope of 
relief that we are at present acquainted with, lies 
in a free incision made down to the bone, in the 
direction of the original wound ; and even of the 
efficacy of this, I am sorry I cannot offer testi- 
mony from my own practice, having failed in 
every case in which I tried it." Some of these 
cases recover, or at least improve, by time ; a re- 
sult to be expected, when it is recollected that the 
numbness from division of a branch of a nerve 
often disappears. The general health, in such 
cases, should be attended to ; all pressure on the 
wounded part avoided, and gentle frictions, with 
a liniment containing belladonna, tried, especially 
if there be pain. 

The occurrence of blindness from injury of a 
branch of the fifth pair is instructive, because, as 
Mr. Wardrop observes, it throws light upon a 
question of importance in the treatment of amau- 
rosis, the efficacy of superficial impressions in 
rousing the sensibility of an amaurotic retina. 
•Some appear to undervalue, or even discard the 
use of stimulating applications to the vicinity of 
the eye in cases of amaurosis, such as blisters, 
sternutatories, liniments, rubefacients, sinapisms, 
or pungent applications to the conjunctiva itself : 
but when we see violent sneezing produced by the 
impression of light, and recollect the other proofs 
01 connexion of function between the nerves here, 
we are more than justified in giving trial to such 
means. 

[In some cases, amaurosis has yielded to the 
extraction of one of the teeth of the upper jaw, 
of the same side as the affected eye ; doubtless 



AMAUROSIS. 

~"~ tl)rou „ h thr imp rcssion made directly on rami 
Sns of the fifth pair, and indirectly on *• 

^TitAmns.s fthoi injuht of the Eye. 

Blindness is generally the consequence of a 
violent blow on the eye-ball, although none of the 
visible parts of the organ appear matcna Iy injured. 
What the real extent of the injury in these cases 
may be, is not certain ; but it is very probable that 
the* delicate connexions of the retina with the 
neighbouring structures are injured or severed ; 
or there may be ecchymosis of its structure, or in 
the cells of the hyaloid membrane. Vision, in 
such cases, is greatly impaired, or even totally 
lost ; and the pupil is generally irregular in shape 
and dilated. If the accident be followed by in- 
flammatory action, the usual appearances of inter- 
nal inflammation of the eye-ball are added. The 
prognosis, in these cases, must be very cautious ; 
because the prospect of recovery depends upon 
the extent of the injury, which cannot be ascer- 
tained. If vision begins to improve some hours, 
or even days, after the accident, which is often 
the case, further improvement may be anticipated. 
In such cases it may, perhaps, be suspected, that 
there has been more of concussion than actual 
destructive disorganization, and, therefore, gradual 
recovery may be expected. Even if the improve- 
ment in vision be still slower, but progressive, 
perfect cure will probably follow. But if vision 
be greatly impaired or destroyed, with irregular 
and dilated pupil, and without any amendment 
after some weeks, the worst may be apprehended. 
When the injury, which is often the case, extends 
to the iris or lens, and terminates in cataract, other 
considerations, foreign to the present inquiry, sug- 
gest themselves. 

The first care of the practitioner, in cases of 
this description, is to avert or allay inflammation, 
by cold applications to the eye, local and general 
bleeding, purgative medicine, and abstemious diet. 
The inflammation sometimes assumes a chronic 
character, proceeding to disorganization of the eye, 
as rheumatic inflammation does, and cannot be 
arrested by the usual means. Whether, in such 
cases, recourse should be had to mercury, is a 
doubtful question ; but experience does not en- 
courage the practice. In this chronic state of the 
disease, blistering is indicated, and may be resort- 
ed to with advantage. Under any circumstances, 
after all inflammation, or danger of inflammation, 
has subsided, efforts should be made to rouse the 
sensibility of the retina by external impressions. 
The means of effecting this object, which are ap- 
plicable to this case, as well as to every other of 
loss of sensibility of the retina, without inflam- 
matory action, are, blisters, sternutatories, pungent 
applications to the conjunctiva, and electricity; 
all which may be tried without injury, and with 
some hope of success. The conjunctiva may be 
conveniently stimulated by the fumes of ammonia, 
or by the vapour of ether evaporated from the 
palm of the hand, as suggested by Mr. Ware. 

It has already been stated that amaurosis is 
caused by various diseases or habits, affecting the 
nervous and vascular systems generally. Such 
diseases or habits are either debilitating, as hemor- 
rhage and menorrhagia, diarrhoea, venereal indul- 
gence, suckling ; or they are calculated to accele- 



AMENORRHEA. 



80 



rate vascular action, and produce a general ple- 
thoric condition, as suppression of accustomed 
discharges, drunkenness, and gluttony. Metasta- 
sis of diseases, as of gout or rheumatism, or the 
removal of cutaneous eruptions, may often be 
found a cause of amaurosis. Diseases affecting 
the optic nerve by pressure, or involving it in 
some specific disorganization, as aneurism, exos- 
tosis, tumours of various kinds, fungus haematodes, 
cancer, and caries of bones of the skull, necessa- 
rily produce imperfection or destruction of the 
functions of the retina. Diseases within the head, 
as rupture of vessels, ill-balanced circulation, soft- 
ening, hydrocephalus, enlargement of arteries, and 
tumours, are some of the most frequent causes of 
amaurosis. General disturbance of the functions 
of the nervous system, not depending on disease 
of the brain, as hysteria, and those affections 
known under the common term nervous diseases, 
are often accompanied by amaurotic symptoms. 
In all these cases the origin of the defective vision 
is obvious to the practitioner, and the nature of 
the origin suggests the treatment. The amauroris, 
in many of them, is merely the symptom, which 
disappears upon the removal of the remote dis- 
ease. The history and treatment of amaurosis 
depending on the causes just now enumerated, are 

not, therefore, detailed here. . T 

Arthur Jacob. 

AMENORRHEA. Amenorrhcea has been 
usually divided into retention and suppression of 
the menses. Under this head we shall also con- 
sider vicarious menstruation. 

I. EMAXSIO, Oil llETEXSIOX OP THE MENSES. 

The non-appearance of the menstrual discharge 
at the usual age does not, in itself, constitute a 
disease. The condition of the bodily develope- 
ment must chiefly be taken into consideration, for 
the age at which the ovarian functions are first 
manifested varies exceedingly. Instances of very 
precocious puberty are numerous ; neither is it at 
all uncommon to meet with cases where the men- 
strual discharge does not occur till a very late 
period of life : but if the general health is not 
affected, medical interference will be rarely requir- 
ed. Climate has a marked influence over the 
period of puberty. Whilst in sultry regions sex- 
ual maturity will usually take place at the age of 
eight or ten years, in colder countries it is deferred 
till eighteen or twenty ; and in Lapland, accord- 
ing to Linnaeus, women will often menstruate only 
during the summer months. 

[Mr. Roberton (Edinb. Med. and Surg. Jour- 
nal, Oct. 1832, and Lond. Med. Gazette, July 21, 
1843,) has endeavoured to show, that the age of 
puberty is as tardy in the colder as in the tropical 
regions, and that were marriages to take place in 
England at as juvenile an age as they do in Hin- 
dostan, instances of very early fecundity would 
be as common in England as they are in that 
country. He is of opinion, that early marriage 
and early intercourse between the sexes, where 
found prevailing generally, are to be attributed not 
lo any peculiar precocity, but to moral and politi- 
cal degradation, exhibited in bad laws and customs, 
the enslavement more or less of the women, igno- 
rance of letters, and impure or debasing systems 
of religion. He has also shown from statistical 
evidence, that menstruation does not occur more 

Vol. 1—13 H* 



early in the negress than in the white female. 
(Dunglison's Human Physiology, 5th edit., ii. 
348. Philada., 1844.)] 

In temperate climates, the usual period of pu- 
berty is about fourteen years of age ; and when 
the signs are delayed much beyond that age, or 
when the sexual developement takes place, but is 
not followed by the consequent monthly discharge, 
amenorrhcea may be said to exist in the form we 
are now describing. The two conditions of body 
are, however, essentially different. In the former, 
puberty itself is delayed, whether from idiosyn- 
crasy, from want of constitutional energy, or from 
defective organization. In the latter, puberty ex- 
ists ; the ovaria and the uterus are organically 
matured ; but their peculiar function is suspended. 

In the former condition, we meet with young 
women of eighteen or twenty years resembling 
children in conformation, with a weak and lan- 
guid frame, a feeble circulation, attenuated, colour- 
less, and of stinted growth. The case is obviously 
one of constitutional debility, and, only as such, 
requires medical treatment. Should the general 
powers be renovated by time, or the judicious 
employment of tonics, a nourishing diet, salubri- 
ous air, and well regulated exercise, the menstrual 
discharge will either take place with other signs 
of puberty, or the case will become of the descrip- 
tion above alluded to, and presently to be noticed. 
But puberty may also be delayed with another 
condition of body, where the general health and 
strength continue unimpaired, the growth proceeds 
as rapidly as in others, the circulation is active, 
and the frame vigorous ; but there are no protu- 
berant mammas, no sexual propensities, a slight 
beard grows on the upper lip, and the general 
characteristics resemble those of a male. In such 
a case the probabilities are that the ovaries are 
either absent, or have become so diseased that 
their functions are entirely lost. A striking in- 
stance is related by Mr. Pott, where a precisely 
similar state was artificially induced by removal 
of the ovaries in a young woman in St. Bartholo- 
mew's Hospital, although, previously to the ope- 
ration, menstruation and all the signs of puberty 
had regularly existed. In such organic defects 
medicine is of no avail ; though, under the possi- 
bility of the ovarian functions being interfered 
with by the pressure of some neighbouring tu- 
mour, the use of iodine, potass, mercury, or other 
medicines to promote absorption, might be advis- 
able. 

When, at the usual age of puberty, a decided 
change in the system is observed, and a struggle 
is evidently taking place to bring about the sexual 
functions, although followed by no actual devel- 
opement, we may conclude that the defect is only 
in degree, and that, by proper assistance, natuio 
will accomplish her object. In some cases, the 
failure may be said to be merely local : the mam- 
mae are enlarged, the pelvis has become capacious, 
the pudenda covered with hair, puberty is estab- 
lished, but the menstrual discharge does not take 
place. There are now peculiar symptoms set up ; 
head-ach, with a sensation of fulness and throb- 
bing, a flushed countenance, heaviness, pains in 
the back and limbs, and a full pulse, generally 
remarkably slow, though, in some cases, accele- 
rated. There appears to be either a torpor of the 



90 



AMENORKHtEA. 



uterine vessels, which ought to secrete the men- 
strual discharge, or (as some have supposed) a 
spasm of their extremities. The causes of this 
condition are generally to be found in the previ- 
ous habits of the patient ; for it is most frequently 
met with in those who have led sedentary and 
indolent lives, who have indulged in luxurious 
and gross diet, and been accustomed to hot rooms, 
soft beds, and too much sleep. The ramedies are 
usually successful, and rapidly so. In the first 
place, the overloaded circulation is to be relieved 
by a brisk purgative, abstemious diet, and the ab- 
straction of blood ; if the symptoms of plethora 
are strongly marked, bleeding from the arm in 
considerable quantity may be required ; but, in 
general, the application of leeches to the labia, 
pubes, groins, or os uteri, or cupping on the loins, 
will be sufficient. Bleeding from the foot, either 
by leeches or from a vein, was formerly preferred ; 
and many practitioners of the present day still 
recommend it, as equally salutary and more pala- 
table to the patient. The purgatives most effica- 
cious in such cases are those which not only un- 
load the vessels, but stimulate the rectum : aloes, 
colocynth, or senna and the neutral salts, are pre- 
ferabfe ; and, in addition to these plans, pediluvia, 
either of simple hot water, or made stimulating 
by the addition of mustard-flour, may be used for 
half-an-hour, night and morning. This treatment 
should be persevered in till the symptoms of ple- 
thora disappear, when it may be suspended, and 
merely a free action of the bowels kept up by the 
daily use of an aloetic purgative, either till the 
menstrual discharge comes on, or till, at the end 
of about a month, the congestive symptoms again 
are perceived, to be again similarly treated. Ex- 
ercise, especially on horseback, will materially 
ussist in promoting the desired effect, and, of 
c-ourse, all the old habits of self-indulgence are to 
be entirely broken through. Should these plans 
fail, we must have recourse to those remedial 
agents which have been supposed more particularly 
to have the property of exciting uterine torpor, 
and which we shall notice in considering the next 
description of cases. 

In these, as puberty approaches, there is a 
marked derangement of the general health, from 
the powers being unequal to the impending strug- 
gle. The patient has been, perhaps, growing 
rapidly, and has perceptibly become much emaci- 
ated ; the face and lips are pallid ; the hands and 
feet cold, particularly the latter ; there is great 
lassitude, and the least exertion produces fatigue ; 
the tongue is foul, the bowels are costive, the 
appetite is defective and irregular, the pulse slow 
and feeble. A more aggravated set of symptoms 
gradually supervenes ; the complexion becomes 
peculiarly sallow, often of a greenish tint ; and 
hence the name frequently given to this stage of 
the disease, green sickness, or chlorosis : (see 
Chlorosis.) Every part of the system partakes 
of the general torpor ; the circulation becomes 
still more languid ; and the blood seems, as it 
were, to stagnate in the veins. The digestion is 
nearly gone, the tongue covered with a dirty coat, 
and indented, a* the edges, by the teeth ; the 
breath is fetid, and there are frequent acid or 
offensive eructations, with air rumbling in the 
bowels, which are generally obstinately confined ; 



and when ihev are acted upon by medicine, the 
motions are dark and foul. The appetite is irre- 
gular and capricious ; so that the most ind.-est.l.le 
substances are often craved and devoured with 
greediness ; chalk, slate-pencils, sealing-wax, til- 
low and dirt , for it is by no means true that the 
Ion-ins is always for articles which nature points 
out°as~ salutary, as, for instance, anti-acids and 
absorbents. The spirits are weak and depressed ; 
hysterical tears are easily excited ; the girl pre- 
fers a moping solitude ; and decided melancholy, 
with delusions, will occasionally be manifested. 
The absorbents partake of the general debility ; 
and there will be puffiness of the face after sleep, 
and anasarcous extremities in the evening. Pal- 
pitation of the heart will be frequently trouble- 
some, and there will be dyspnoea on the slightest 
exertion ; and along with this latter symptom, a 
short distressing cough. Hence it is that there is 
no disease more frequently mistaken for phthisis, 
and the error is a most serious one ; for much 
injury would be occasioned by the remedies gene- 
rally administered for the latter complaint. 

The causes of this disease may be shortly stated, 
as all those which depress the vital powers, viz. a 
previously delicate and unhealthy childhood, in- 
sufficient or improper food, want of pure air and 
exercise, too close a confinement to study in schools, 
or to labour in crowded manufactories, the de- 
pressing passions, and, in particular, according to 
many, hope deferred, and disappointed sexual 
feelings. 

In treating the disease, the amenorrhea must 
at first be considered as only one of the train of 
symptoms of disorder of the general health. It is 
advisable to begin with an active purgative, which 
will often bring away a large collection of highly 
offensive motions, with manifest relief to the pa- 
tient. Small doses of blue pill may be afterwards 
occasionally repeated, and purgatives of a warm 
and stimulating character taken every morning. 
combined with a small quantity of some bitter 
extract or infusion, until the tongue appears 
cleaner, and the secretions from the bowels are 
more healthy. A more decided tonic of the vege- 
table class, along with myrrh, rhubarb or aloes, 
and ammonia, will gradually prepare the stomach 
for the metallic tonics, and above all others for 
that medicine most useful in these cases, namely 
iron, which, in one form or another, may be nearly 
always taken with benefit in a torpid condition of 
the venous system. Upon the whole, perhaps, the 
Griffith's mixture (mistura ferri composita of the 
Pharmacopoeia) is the most serviceable of uV 
artificial preparations of iron. At the same time 
the bowels must be kept fairly opened with the 
above-mentioned purgatives, those containing alms 
being preferable. The diet must be, at first, light 
and easily digestible ; and, as the stomach is pre- 
pared for an improved and more nourishing food, 
wine, meat, and eggs may be taken. Gentle exer- 
cise in a carriage or on horseback, particularly tlie 
latter, with sea-bathing or the shower-bath, may 
be ventured upon cautiously as the strength im- 
proves. A pure air is very desirable, and on tint 
account, when the patient has a little advanced, 
nothing is more efficacious than a residence at 
Tunbridge- Wells, or some other places whore 
chalybeate springs abound, combining the advan- 



A M E N R R H CE A. 



91 



tages of change of scene, a salubrious atmosphere, 
amusement to the mind, and the internal use of 
the mineral water. 

With returning health and strength, the func- 
tions of health may be expected, and, amongst 
them, the menstruation ; but it often happens that 
in this particular respect we are disappointed, and 
wo now come to the trial of those remedies which 
have been found by experience to act either 
directly or indirectly in promoting menstruation. 
Foj the more complete consideration of this class 
of medicines, we refer to the article Emmika- 
gogces. It will be sufficient here to mention 
those which are considered most serviceable at 
the present day. 

Some act by stimulating the neighbouring parts, 
the rectum and the bladder; such are the more 
drastic purgatives, aloes and melampodium ; ene- 
mata of soap or turpentine ; tincture of Spanish 
fly ; savine, turpentine, and some of the balsams, 
internally. A combination of myrrh, aloes, sul- 
phate of iron, and the essential oil of savine, has 
been found frequently of great utility by the writer 
of this article. Warm hip-bathing, hot and stimu- 
lating pediluvia, warm frictions to the hypogastric 
a^d lumbar regions, electricity or galvanism ap- 
plied to the pelvis, have by many been proved 
beneficial ; and it is often of great service to com- 
bine with one or other of these plans, the appli- 
cation of leeches to the groins, labia, or os uteri, 
or to the feet, once a month. Compression of the 
crural arteries by the tourniquet was formerly 
much in vogue, by which a larger quantity of 
blood was thrown upon the uterus. Irritation of 
the os uteri itself by means of bougies has been 
proposed, or the injection of a stimulating lotion 
into the upper part of the vagina, which has suc- 
ceeded in a considerable number of casos ; for this 
purpose a solution often drops of liquor ammonia? 
in an ounce of milk has been advised once or 
twice in the twenty-four ho'irp, and on several 
occasions the effect has been very rapid. Of 
supposed direct emm»nogoT[ues, the madder and 
spignel, formerly so much vaunted, have now 
fallen into disr<?p"te. The only medicines of 
modern days, which can at all lay claim to that 
character, are iodine and the ergot of rye. Dr. 
Coindet, of Geneva, considers the former the most 
powerful and certain emmenagogue we possess, 
and attributes its success in bronchocele to the 
sympathy which the uterus and the thyroid gland 
manifest for each other. The ergot has been 
extensively used in various conditions of the ute- 
rus, and certainly seems to exert peculiar and 
powerful action on that organ, which may, per- 
haps, deserve the name of specific. In the cases 
before us, it may be tried in the form of decoction, 
infusion, or powder. The writer has given it 
frequently, and, in many instances, successfully, 
in doses of ten grains and upwards, three times a 
day. In very irritable habits it must be cautiously 
administered, as it has been found after a few days 
to produce sometimes violent and even highly 
dangerous spasmodic effects. 

[Dr. Churchill (Diseases of Females ,■ includ- 
ing those of Pregnane}/ and Childbed; Amer. 
edit., p. 65 : Philad., 1843,) thinks that the medi- 
cines, of whose power of acting on the uterus there 
is the least doubt, are iodine, ergot and strychnia ; 



yet it may be questioned whether these, or any 
agents, have an efi'ect which adapts them for all 
cases, and merits for them the title of emmena- 
gogues. (SeeE)DtESACoGuF.s.) Dr. Ferguson, 
indeed, (Library of Practical Medicine, 2d Amer. 
edit., iii. 302,) classes these and other agents 
under the title of « nostrums ;" and the truth 
would seem to be that there is, in the existing 
state of knowledge, no remedy that acts special!} 
upon the uterus, so as to restore the menstrua! 
discharge when obstructed. They are all indi- 
rect agents; and, inasmuch as amenorrhcea may 
be dependent upon opposite pathological condi- 
tions, the remedies have to vary accordingly. 
(Dunglison's Practice of Medicine, 2d edit., ii. 
392 : Philad., 1844.)] 

There is one circumstance to be kept in mind 
in the management of these cases. The menstrual 
discharge may be secreted regularly, but there 
may be no exit, the passage being closed by an 
imperforate hymen, or an obliteration of the va- 
gina, either from original malformation or from 
disease. In these cases, in addition to the periodi- 
cal recurrence of the symptoms of menstruation, 
there is a gradual enlargement of the abdomen 
from the retained fluid collected in the uterus, so 
that unjust suspicions of pregnancy are apt to be 
raised. A manual examination at once detects 
the impediment, and it is easily removed by a 
surgical operation. [The obstacle may exist at 
the external opening : at other times, a membrane 
covers the os uteri, or the canal of the cervix may 
be imperforate. In the last case, Dr. Churchill 
proposes to make an artificial canal, by means of 
a trocar, or an instrument resembling that used by 
Stafford for dividing strictures of the urethra ; but 
it need scarcely be said, that such an operation 
should be decided upon and executed with exceed- 
ing caution. Where a membrane over the os 
uteri is the obstacle, it may be punctured or rup- 
tured, and a probe or small bougie may be passed 
into the uterus, as described under Dysmenor- 
rhea. (Practice of Medicine, loc. cit.)] 

II. Suppression of the menses. 

Suppression of the menses may take place at 
any time after menstruation has been once fairly 
established, and may be either acute or chronic ; 
in the latter case it is most commonly the effect 
of disorder of the general health, although by 
females it is apt to be considered as the cause. 
Acute suppression generally arises from some 
cause acting immediately previous to or during 
the menstrual period ; such as an attack of fever, 
exposure to cold or wet, anxiety of mind, frights, 
or any agitation of a depressing character, a meal 
of improper or indigestible food, &c. A few 
years ago, a very interesting case was communi- 
cated by Dr. Burrows to the Medico-Chirurgical 
Society, of acute suppression ending in mania and 
catalepsy, which was occasioned by sexual inter- 
course, under very exciting circumstances, during 
menstruation. Some have argued that in these 
cases the amenorrhcea is merely the effect of fever 
excited in the system, and that the secretion from 
the uterus is checked, as all other secretions arf; 
in fever. But this idea is not always correct : 
for often, during menstruation, the sudden appli- 
cation of cold or wet will stop the discharge, long 
before the existence of fever, and without any 



A M E X R R H CE A — ANiE M I A 



subsequent fever at all. In such instances, it the 

patient puts her feet into warm water, gets into a 
hot bed, and takes some diaphoretic drink or 
medicine, tbc discharge will return in a few hours. 
But in many cases the acute suppression is pre- 
ceded or accompanied by general fever, quick 
pulse, hot and dry skin, coated tongue, a flushed 
countenance, violent head-ach, throbbing of the 
temples, and pain in the back and limbs. In 
habits at all plethoric, abstraction of blood is 
desirable ; an emetic, followed by an active saline 
purgative, may be also given ; a warm bath, hot 
fomentations to the abdomen, and diaphoretic 
medicines, combined with opium, will then be 
found of the greatest service ; and if, after we 
have reduced the immediate symptoms, the men- 
struation is still suspended, we may consider it a 
case of chronic suppression. 

Chronic suppression of the menses is either the 
consequence of a previously acute attack, or is the 
result of impaired health. In the latter case it 
often conies on slowly, the menstrual discharge 
either becoming gradually more and more scanty, 
or the intervals between the periods being more 
and more protracted, till at last there is a total 
suppression. In either of these cases there is 
much the same train of symptoms as described in 
the history of retention of the menses ; but there 
is almost always much more head-ach and pain in 
the loins. The causes are also similar, and the 
treatment varies only according to the peculiar 
derangement of health which produces or accom- 
panies the suppression. It would be useless to 
repeat the details, and it will be only necessary to 
state, that, here even, the discharge may be ob- 
structed by a closure of the vagina from ulceration 
after a difficult labour, or as the effect of irritating 
discharges. The possibility of pregnancy should 
also be kept carefully in view, as the cause of the 
suppression ; and this caution is even applicable 
to cases of retention of the menses, for a previous 
menstruation is not absolutely necessary for con- 
ception, but only that condition of the sexual 
organs which is directly preparatory to menstrua- 
tion. Sir Everard Home has stated a case where 
menstruation occurred for the first time in life, 
after the birth of more than one child, the second 
pregnancy taking place during lactation. Professor 
Frank has related a still more remarkable instance, 
of a patient who bore three successive children, 
and never menstruated at all, either previously or 
subsequently. 

Vicarious mexsthuatiox. 

The consideration of this curious freak of nature 
is most appropriate to the history of amenorrhcea, 
because it does not occur except when menstrua- 
tion is checked. It appears to depend principally 
upon a torpid or amenorrhoeal condition of the 
uterus ; and the periodical evacuation being pre- 
vented, either by accidental causes immediately 
before the expected period, or by a previous indis- 
position, a larger quantity of circulating fluid is 
thrown back upon the system, and forces a pas- 
sage for itself at some distant part. It also usually 
seems necessary that the vicarious outlet should 
be already in a weak, irritable, or disordered con- 
dition. Accounts are given of this periodical 
discharge of blood taking place from the lungs, the 
aostrils, the stomach, or the bowels ; and these 



are not uncommon cases. But instances have 
also occurred where the flow has been from the 
bladder, the nipples, the umbilicus, the eyes, the 
ears, the sockets of the teeth, the skin generally, 
and also from open ulcers in various parts of the 
body. It is the practice of some to bleed in these 
eases, to diminish arterial action ; but it does 
harm, except in very plethoric constitutions, when 
leeches to the labia, groins, or os uteri, a day 
before the expected period, would be much more 
beneficial. The object to be gained, is not only 
to control and prevent the hemorrhage from the 
particular part by the proper remedies, but also to 
rouse the torpid uterus into action. In the inter- 
vals of the attacks, metallic tonics, and especially 
iron, should be freely given, combined with myrrh 
and aloes ; and some of the more direct emmena- 
gogue plans may be tried immediately before the 
expected period. Opium has proved of great ser- 
vice in many of these cases, combined according 
to the peculiar condition of the health, and the 
character of the part morbidly in action. Thus it 
may be given in conjunction with the mineral 
acids, or the superacetate of lead, a few days 
before the expected hemorrhage from the lungs; 
or in combination with the subnitrate of bismuth, 
where the stomach has been the vicarious outlet. 
[In all cases it is important to inquire into the 
cause of the aberration, both as regards the system 
in general, and the uterus in particular; and, 
moreover, to attend to the condition of the part 
whence the vicarous discharge proceeds. It has 
been properly remarked, that the state of the organ 
probably assists in determining the discharge to it; 
hence, vicarious haemoptysis is, perhaps, of more 
consequence than any other form ; and partly, 
also, because there is danger — even if the dis- 
charge should be a mere transudation of blood 
through the parietes of tolerably healthy containing 
vessels, that a predisposition may be left to some 
other pulmonary affection.] .-, T 

[AMYGDALITIS. See Thhoat, (Diseases 

OF THE).] 

AX^EMIA. This term is derived from a, pri- 
vative, and aifia, blood, and means, therefore, a 
deficient quantity of the circulating fluid, or blood- 
lessness. 

The haematosis, or formation of the blood, is 
begun in the stomach and completed in the lungs. 
A morbid state of any one of the organs or func- 
tions which concur to effect the haematosis may 
lead to a state of anaemia. It is in this manner 
that we have a defective state or quantity of the 
blood in some forms of dyspepsia, especially chlo- 
rosis. It is in this manner, too, that the workers 
in certain coal-mines have, from a deficiency in 
the pulmonary function, been struck with anaemia. 
A similar state of anaemia has also arisen from 
disease in some particular organ forming a part of 
the class of those which contribute to the haema- 
tosis ; a case, the exact seat of which is often ob- 
scure. It is scarcely necessary to add, that a state 
of anaemia is also the immediate result of losses 
of blood either artificially or by natural hemor- 
rhage. These are precisely the cases to which the 
term anaemia has been variously and too indiscri- 
minately applied. M. Andral describes anaemia at 
great length, and has distinguished different forms 



ANEMIA. 



93 



of local anaemia, or anaemia of the individual 
organs. 

The case of chlorosis, to which the term anae- 
mia has been applied adjectively, will be treated 
of distinctly in this work. So will the case of 
ancemia from actual loss of blood. In the present 
article we purpose to describe, 1. that form of 
anaemia which has occurred in coal-mines ; and, 
2. that other form of the disease which has an 
obscure origin in the morbid condition of some 
organ contributing to the hsematosis : 3. to these 
will be added the view taken of anaemia by M. 
Andral, and especially the case of local or topical 
anaemia. 

General anaemia is denoted by extreme paleness, 
especially of those parts which, being covered by 
the thinnest and most transparent investing mem- 
brane, expose the condition of the blood underneath 
them, as the prolabia, the tongue, the gums, the 
internal surface of the cheeks, &c. The face, the 
hands, and the general surface are pallid, and 
slightly waxen or icterode in their hue. There 
are vertigo, faintishness, palpitation, and an im- 
paired action of the organs generally, especially 
of the stomach and bowels, digestion being de- 
ranged, with flatulency, constipation, &c. 

I. The following description of the anaemia of 
the coal-miners of Anzain is translated from an 
account given by M. Chomel, in the article Arte- 
tnie, of tbe. Dictionnaire de M'edecine : 

" All the workmen employed in one of the gal- 
leries of the coal-mines of Anzain fell sick in the 
summer of the year 11, although that gallery had 
been wrought for some time. The workmen of 
the adjoining galleries escaped, although the only 
observable difference was that they were less ex- 
tensive, and the ventilation less difficult. The 
disease began with violent colic, with tympanitic 
distension, black and green alvine evacuations, to 
which were added dyspnoea, palpitations and great 
debility. These symptoms subsided in the course 
of twelve days, and then those of anaemia ap- 
peared : the face assumed the colour of wax ren- 
dered yellowish by time ; the blood-vessels had so 
entirely disappeared that not a trace of them could 
be found where they are usually most obvious, as 
in the conjunctiva, eye-lid, internal mouth ; the 
arterial pulsations were feeble ; these appearances 
continued even during attacks of fever, which 
came on accidentally in some of the patients : ex- 
treme feebleness ; great anxiety ; slight oedema of 
the face ; palpitations ; shortness of the breath on 
the slightest effort ; perspirations ; — such were the 
symptoms : although the appetite was not lost, 
yet the digestion was imperfect, and there was a 
progressive loss of flesh. 

" This state continued during six months or 
a year, sometimes terminating in death, preceded 
by the symptoms which first appeared. The 
Soctete* de l'Ecole de Medecine was consulted. 
Four patients were conveyed to Paris, and placed 
under the care of M. Halle. A nutritious diet, 
infusion of hops and gentian, the "vin antiseor- 
butique" were conjoined with mercurial frictions. 
During this treatment one patient died ; on exa- 
mination, the arteries and veins were found desti- 
tute of coloured blood, and containing only a little 
serous fluid ; incisions through the muscles gave 
rise to no flow of blood, except a little from those 



of the thigh. The absence of blood, which was 
in accordance with the external phenomena, led to 
the disuse of mercury, and to the substitution of the 
internal use of iron (limaille porphyrisee,) in the 
dose of a "gros" daily, under the form of opiate, 
with tonics. In eight or ten days there was an 
evident amendment : several veins appeared under 
the skin of the fore-arm ; the digestion improved ; 
the shortness of breath diminished. On each suc- 
cessive day the patients pointed out, as discoveries, 
new veins, which had not been perceived the day 
before. The amendment was progressive, and 
quite complete when these men returned home. 

" Similar morbid appearances were observed in 
some of the patients who died at Anzain. And 
the same mode of treatment proved successful 
both there and at Dunkerque, whither some of the 
sufferers had also been conveyed." 

The want of sun and the want of air seem to 
have been the causes of this singular malady. 
These important agents appear to be essential to 
the hannatosis. [See Am, change of.] The 
effects of the want of blood are illustrated in an 
interesting manner. But the consideration of this 
point is reserved for a distinct article. 

II. The origin of the second form of anaemif 
is more obscure. "We shall illustrate the subjec 
by an abstract of a case published by Dr. Combe 
in the Transactions of the Medico-Chirurgical 
Society of Edinburgh. 

Dr. Combe first visited his patient in July, 1821. 
He looked like a man recovering from syncope : 
the symptoms were pallor, languor, breathing 
easily hurried, pulse 80 and feeble, tongue covered 
with a dry fur ; the bowels relaxed, the stools dark 
and fetid ; thirst, want of appetite, rejection of 
food ; no pain ; no detectible organic disease. 
The patient was forty-seven, married, of regular 
habits, and engaged, first in agriculture, and ther 
as a servant to a corn-merchant ; he was never 
blooded. These symptoms had stolen upon him 
during two months ; he said his head troubled 
him ; and the feet were cedematous. Some tonic 
medicine, a mild nutritious diet, and wine were 
prescribed. Afterwards iron, mercury, opiates, 
and astringents were given. Towards the end of 
September, he tried a sea-voyage, and a chalybe- 
ate spring. He died in January, with all the 
symptoms of hydrothorax. On examination, not 
a drop of blood flowed on dividing the scalp ; the 
dura mater was moist, and displayed few vessels, 
and those empty ; near the vertex, to the left, 
there was an ossification ; the pia mater was pale, 
its blood-vessels containing a pale serum, and air : 
a slight effusion under the arachnoid. The brain 
was soft and pultaceous, with few vessels, and 
little difference of colour between the cineritious 
and medullary portions ; the ventricles contained 
two drachms of serum ; and about two ounces 
were found at the basis. The lateral sinuses were 
moderately filled with pale fluid blood ; the arte- 
ries at the basis were empty. In the thorax there 
were three pounds of a lemon-coloured serum . 
the lungs were of a pale grey, without any mark 
of gravitated blood. The pericardium contained 
an ounce of serum. The heart was pale ; the 
right ventricle contained a pale coagulum ; the 
left was empty. The inner coat of the aorta was 
of a fine red colour. There was some moisture 



in 



A N JE M I A . 



in the abdomen ; the liver was of a light brown 
colour ; the spleen alone was of its natural colour, 
and soft. The arteries were universally empty, as 
were the jugular and femoral veins ; the lower 
cava alone contained any blood. 

The whole case, and, indeed the whole subject, 
is exceedingly obscure. It does not appear that 
any examination of the thoracic duct was made, 
which is much to be regretted. 

III. We now proceed to notice the different 
forms of local anaemia ; and, in doing so, we shall 
chiefly draw upon the recent work of M. Andral. 
(Prtcis d' Anatomic Pathologique, p. 73.) 

M. Andral traces the cases of local anaemia, 1. 
to a diminution of the principal artery; 2. to cer- 
tain affections of the nervous system ; for instance, 
may not the stomach become anaemious like the 
cheek ? 3. to the hyperemia of other organs ; 4. 
to a previous state of Iryperamia in the organs 
affected with anaemia ; 5. lastly, without being 
able to trace it to any of these causes, a state of 
anaemia is sometimes seen in some particular organ. 
M. Andral adds that he has observed this state of 
anaemia particularly in the brain, the heart, the 
liver, the stomach, and some other parts of the ali- 
mentary canal, and some of the voluntary muscles. 

With a state of anaemia of an organ, that of 
atrophy is sometimes conjoined. 

With anaemia of the membranes, we often ob- 
serve an augmentation of their secretions ; this is 
seen in the serous and mucous membranes, and in 
cutaneous textures. 

When anaemia is induced in an organ by the 
sudden obliteration of its principal artery, as by 
ligature, gangrene is the result. 

M. Andral concludes this subject by the impor- 
tant remark, that the symptoms of the anaemia of 
an internal organ are sometimes observed during 
life : convulsions and delirium arise from anaemia, 
as well as hyperemia, of the brain. Similar 
states of the stomach may lead to their peculiar 
symptoms respectively. 

It is, indeed, quite plain that the state of anae- 
mia, of which the actual loss of blood is one of 
the most frequent forms, leads to phenomena 
which require to be carefully distinguished and 
appropriately treated. For the fuller discussion 
of this important subject, we refer our readers to 
the article Blood. ,, Tx 

Marshall Hall. 

[Anjemta is generally applied to that condition 
of the system in which there is paucity of blood : 
more properly it, might be termed Hypscmia, or 
Oligemia. It likewise includes that condition in 
which the watery portions of the blood predomi- 
nate largely ; or what has been called Hydroasmia, 
or Hydremia. 

When blood is drawn from a patient affected 
with general anaemia, it is found to possess a 
smaller proportion of crassamentum, and this is 
loosely cohering : the quantity of serum, on the 
other hand, is greatly augmented. The essential 
character of the blood of the anaemic is the oppo- 
site to that of the plethoric — paucity of globules. 
In 16 cases of incipient anaemia, M. Andral 
(JTasmatologie Patkologique, Paris, 1S43,) found 
the proportion to be 109 in place of 127, the 
healthy proportion ; and in 24 cases of confirmed 
anmmia, 65. In spontaneous anaemia, slight or 



considerable, he found the globules, alone, dirmn- 
bhed in quantity : the fibrin and solid matters 
of the serum possessed the healthy proportion. 
In the anemia that follows hemorrhage, the glo- 
bules, alone, may have their proportion dimin- 
iehed, but if the hemorrhage should augment, or 
be renewed, the blood soon begins to lose some of 
its other principles, and, along with the globule*, 
the fibrin and the albumen of the serum diminish. 
In anaemia induced by inappreciable modifications 
of the organism, the composition of the blood was 
affected as in spontaneous hemorrhage : thus, the 
globules alone were found to be diminished, the 
fibrin and albumen of the serum remaining the 
same. This was the case in several pregnant 
females, whose blood had lost globules without 
any diminution of its fibrin. Andral found the 
mean proportion of globules in them the same as 
in cases of slight anaemia. 

Owing to the proportion of fibrin to the red 
globules being increased, the buffy coat is not an 
uncommon phenomenon in anaemia, and especially 
in chlorotic cachexia (see Chlorosis); for it 
appears that whenever there is an increase in the 
proportion of fibrin to the red globules, and, at 
the same time, the coagulation of the blood is not 
too rapid, the fibrin accumulates at the surface of 
the blood, and the buff appears. 

Whenever a certain diminution takes place in 
the proportion of the globules, a bellows' sound is 
heard on auscultating over the arteries. According 
to M. Andral, this is connected with the impove- 
rishment of the globules, inasmuch as it is not 
heard when the fibrin alone is diminished in quan- 
tity. The same sounds are heard as in chlorosis 
(q. v.). Chlorosis, indeed, belongs to anaemia; 
and amenorrhcea is not unfrequently accompanied 
by the same anaemic condition. 

The different functional phenomena, which are 
characteristic of anaemia, generally occur in a gra- 
dual manner, and it is long before they induce so 
much disease as to cause death. In the very thin 
state of the blood that accompanies it, hemorrhage 
readily occurs from parts in which the vessels are 
but loosely protected by the tissues in which they 
creep, — as from the mucous membranes, — the gas- 
trointestinal especially, — and these hemorrhages 
greatly hasten the fatal termination, both by the 
increased exhaustion which they induce, and by 
their laying the foundation for hydropic, or other 
mischief. 

On the dissection of those who have died of 
anaemia, the tissues have been found pale, and the 
vessels and heart almost exanguious. The heart, 
loo, is often atrophied, and its tissue softened and 
flabby, especially if the disease has been of long 
duration. The intestinal canal is frequently also 
pale, and the serous cavities and cellular membrane 
are infiltrated with serous fluid. 

In the treatment, it is all important to inquire 
into the pathological cause, and to remove it, 
where practicable. In almost all cases, it is essen- 
tial to put the patient on nourishing diet, and 
especially where the anaemia has been caused by 
imperfect nourishment; yet care must be taken in 
the very impressible condition of the system which 
exists in these cases, that undue excitement be not 
induced. The respiration of pure air is likewise 
all important. 



ANASARCA. 



95 



The best therapeutical agents are, the prepara- 
lions of iron, — the iodide, subcarbonate, citrate, lac- 
irate or tartrate, for example. The iodide, in the 
writer's experience, is the best form. Dr. C. J. B. 
Williams, (Principles of Medicine, Amer. edit., 
sy Dr. Clymer, p. 143, Philad., 1844,) considers 
\t to be most speedily efficacious. It not unfre- 
quently, however, disagrees, and it becomes neces- 
sary to substitute one of the other preparations. 
The different mineral and vegetable tonics may be 
given, hut they have less efficacy. To relieve the 
nervous erethism that always exists to a greater 
or less degree, the hydrocyanic acid is well adapted ; 
and a full dose of opium will often allay the ex- 
cessive vascular and nervous tumult that sometimes 
prevails. Under careful management, with the 
observance of the strictest mental and corporeal 
quietude, the blood may gradually become im- 
proved in its constitution, and the phenomena of 
anaemia gradually disappear. (Practice of Medi- 
cine, 2d edit., p. 456, Philad. 1814.) 

ROBLEY DuNGLISON. 

ANESTHESIA. See Pahalysis.] 

ANASARCA : from dvi, through, and <r«pf, 
flesh. The word used by Celsus, and other ancient 
writers, is v-oadoKa ; or, as is explained by Cselius 
Aurelianus, aqua subter cufem. 

Anasarca occurs under many different states of 
the system : it essentially consists in the effusion 
of serum into the meshes of the cellular tissue, and 
may take place wherever this structure exists. It 
has usually been described as a peculiar species of 
dropsy, and is frequently treated of under this 
head by authors. Such a plan is, however, at- 
tended with very serious inconvenience ; as, in 
every species of effusion, the immediate condition 
of the exhalents varies but little, while that of the 
preceding series of vessels often differs most mate- 
rially. What these different conditions are, we 
shall endeavour to explain under the general article 
of dropsy. In the present article our purpose is 
to give a clear account of the different circum- 
stances under which anasarca takes place ; pre- 
mising, at the same time, that in some cases which 
we shall here treat of, the anasarca is only the 
chief symptom, and that ascites, and even hydro- 
thorax, are occasionally joined with it. 

Anasarca occurs very frequently as an acute 
disease ; but in this case it is usually accompanied 
with the inflammation of some viscus ; and in 
most cases it is the lungs which suffer. The 
dropsy described by Dr. Abercrombie, and to 
which the attention of the profession was drawn 
a few years ago, is of this description : " The dis- 
ease comes on suddenly, and generally affects 
persons in the vigour of life. It is usually as- 
cribed to sudden exposure to cold, especially after 
the body has been previously overheated. The 
first symptom is an oppression and uneasiness in 
breathing ; and, in a short time, frequently in a 
few hours, or in the course of the same day, this 
is followed by the dropsical swelling. The affec- 
tion of the breathing varies considerably in differ- 
ent cases. In some cases there is only a feeling 
of oppression or tightness in breathing, without 
pain or cough : in others there is pain, increased 
by a full inspiration, with sharp painful cough; 
and in others there is great oppression of breath- 



ing, preventing the patient from lying down, ex- 
cept in one particular posture, or even prevent- 
ing him from lying down at all. The pulse is, in 
some cases, a little frequent ; but in others it is 
not above the natural standard. It is sometimes 
of good strength, but frequently rather weak, and 
in some cases irregular. This anasarcous swell- 
ing is commonly observed first in the face ; from 
thence it extends downwards upon the trunk of 
the body, and then to the extremities. This pro- 
gress was, in one case, so remarkable, that, even 
at night, after the patient had been sitting up 
through the whole day, he was affected with a 
great degree of anasarca down to the middle of 
the legs, while the feet and ankles were free from 
it : next day the feet and ankles were affected 
also. This peculiarity, however, does not occur 
universally, for in some cases the swelling is first 
observed in the legs : but, in general, the face 
is affected at a very early period. The urine is 
scanty and high-coloured : in some cases it is co- 
agulable ; in others there is no trace of albumen. 
If the disease be now allowed to go on, the swell- 
ing increases, and the breathing becomes more 
and more oppressed ; it may be fatal in a few 
days, or it may be drawn out to several weeks." 

Dr. Abercrombie remarks, with regard to the 
diagnosis of this disease, that the affection of 
breathing may exist without pain and without 
fever, and that, consequently, there may be some 
danger of mistaking it for actual effusion into the 
chest. With the view which we have of some 
of these affections, such an error would not al- 
ways be very important ; because, if we had other 
evidence that inflammation were present, the oc- 
currence of effusion would not prohibit the most 
active antiphlogistic remedies. But in all the 
cases which we have seen, there has been mani- 
fest pulmonary inflammation, which, if it could 
not be recognised by general symptoms, is always 
easily distinguishable by means of the stethoscope. 
In this, therefore, as in so many other cases, the 
stethoscope is a most important assistant in ar- 
riving at a correct diagnosis. 

The appearances found on dissection suffi 
ciently prove that this affection is of an inflam- 
matory nature, and, of course, equally prove the 
propriety of active antiphlogistic treatment. The 
extent to which this can be carried varies neces- 
sarily with the condition of the disease and the 
constitution of the patient. In more recent and 
lighter cases, a single bleeding, or even a few 
leeches, will be sufficient to remove it ; in other 
cases it requires the greatest firmness and deter- 
mination to carry this remedy sufficiently far. 

A very important illustration of the value of 
bleeding is given in the Edinburg Medical and 
Surgical Journal, by Dr. Graham ; for in very 
few cases has depletion been carried so far, even 
with impunity ; in still fewer has it, when thus 
employed, been attended with success. It is cal- 
culated to caution as well as to instruct. The in- 
flammatory symptoms were detected by the rare 
acumen of the physician, and his diagnosis being 
correct, his treatment was consonant to his diagno 
sis. He had, at the same time, a young man ot 
full and vigorous constitution to treat ; and, with 
this adjunct, his success was striking. But it 
becomes all who shall dare to carry depletion a* 



96 



ANASARCA. 



far as Dr. Graham carried it, to unite his sagacity 
with his boldness; for should the same treatment 
he adopted in cases which have not an inflamma- 
tory origin, or should the patient have a less 
sturdy constitution to endure the remedy, the re- 
sult would most likely be fatal. 

ANASARCA FROM THE RETROCESSION* OF ERUP- 
TION'S. 

The anasarca, which succeeds scarlatina, has 
been mentioned, by Dr. Abercrombie, as analo- 
gous to that which has been just described, and, 
as it appears to us, with considerable reason. The 
first, and hitherto the best account of this disease 
has been given by Dr. Wells, in the third volume 
of the Medical and Ckirurgical Transactions. 
Though this disease has frequently occurred ih 
our practice, we have never yet met with a fatal 
case ; for the morbid anatomy of it, therefore, we 
are indebted to Dr. Wells's paper and to Dr. 
Abercrombie. Burserius, from whom Dr. Wells 
quotes, has remarked that the bodies of several 
persons who had died of the disease about 1717 
having been opened, the lungs, pleura, intercos- 
tal muscles, diaphragm, kidneys, and intestines, 
were found more or less inflamed ; that peripneu- 
mony having hence been considered the original 
disease, and the dropsical swelling only as a con- 
sequence, blood was taken from the arm in the 
succeeding cases, once or oftener, as the occasion 
required ; and that no one afterwards died of the 
dropsy who was thus treated. 

Dr. Abercrombie, in the Edinburgh Medical 
and Surgicul Journal for April, 1818, has related 
the case of a child two years and a half old, who, 
about eight or ten days after he had recovered 
from a mild attack of scarlatina> was observed to 
be anasarcous in the face ; the swelling increased, 
and extended over other parts of the body ; at a 
very early period of the complaint his breathing 
was oppressed ; the pulse frequent, and rather 
small ; the urine very scanty. The swelling in- 
creased ; the breathing became more and more 
difficult ; all the usual remedies were employed 
without benefit, and the child died about the tenth 
day from the first appearance of the anasarca. On 
dissection, considerable effusion was found in both 
cavities of the thorax, and a little in the abdomen. 
The lungs were dark-coloured and remarkably in- 
durated, so as to resemble the structure of the 
liver. This was most remarkable in the right 
lobe ; pieces cut from which sank in water. 

The following case, extracted from Dr. Black- 
all's work, proves still more clearly the inflamma- 
tory origin of dropsy succeeding scarlatina. Sa- 
rah Elliot, ret. 30, was brought into the Devon 
and Exeter Hospital, 1800, — in a state of great 
distress, labouring under universal anasarca, and 
an erysipelatous inflammation of the lower extre- 
mities, with much discharge and deep sloughs on 
the hips and sacrum. The urine coagulated, al- 
though not to the extent sometimes observed, and 
it flowed freely, as it is often known to do, when- 
ever much serum is discharged from the legs. 
Sue had the remains of a florid and sanguine 
temperament, and had been in good health, till 
about two months before, when she was attacked 
With fever, with great redness of the face and ex- 
tremities : soon afterwards she became dropsical, 
and complained of sense of stricture in the chest, 



cough and pain under the left breast. She took 
law doses of cinchona with great advantage. 
She was quite inundated with the discharges from 
the legs, and the increased flow of urine. I he 
erysipelas disappeared, and shortly alter all ves- 
tiges of dropsy : but the above-mentioned sloughs 
had penetrated deeper than was anticipated ; the 
bones became carious, and, about two months 
after, she died exhausted, the anasarca never hav- 
ing returned. 

On examination after death, the kidneys were 
found rather soft and flaccid, and more loaded 
with fat than could have been supposed after so 
long an illness, but in other respects appeared na- 
tural. . There was no morbid appearance in any 
any other viscera of the abdomen. 

The pleura of the left lung bore marks of in- 
flammation, more severe than the common adhe- 
sive, for several small flakes and granula of coagu- 
lated lymph covered it in several parts, principally 
in a spot answering to the seat of pain during 
life ; and that membrane was separated from the 
body of the lungs for about the size of a shilling, 
by a very small deposition of pus. Opposite the 
same spot the pleura costalis was inflamed. In 
other respects the substance of the thoracic vis- 
cera was sound, and there was no unusual quan- 
tity of water in the cavities. 

These two cases sufficiently attest the nature 
of this anasarca, and we shall proceed to its his- 
tory. 

We have already stated that it succeeds the re- 
trocession of the eruption in scarlet fever, but sel- 
dom earlier than three weeks from the commence- 
ment of the fever. It has never, within our know- 
ledge, been observed to appear upon the sudden 
retrocession of the eruption, nor is it peculiar 
either to a mild or severe attack of fever. In all the 
cases which have fallen under our own care, the 
patient has never entirely recovered from the scar- 
latina, but has remained languid and fretful. The 
sore throat has either partially, or, perhaps, en- 
tirely disappeared, and the appetite has slightly 
returned. In short, the patient has appeared con- 
valescent. In this state, however, the patient has 
remained day after day : the same languor has 
continued ; the tongue, after having become 
cleaner, has again been furred, and the appetite, 
though not so defective as during the fever, has 
been exceedingly capricious. The bowels are, at 
the same time, usually costive, and sometimes 
both sickness and vomitings accompany it. 

After this has endured for several days, or some- 
times a month, the face is observed to be rather 
puffed, particularly on first rising in the morning : 
this rapidly increases, and the anasarca in a day 
or two extends over the whole body. According 
to Dr. Wells, however, it is rare for the whole 
body to be affected : and he states likewise that 
the hands are more readily affected than the feet. 
During this time there is also frequently much 
torpor, and we might be induced to suspect that 
effusion had taken place into the brain. In a 
case which presented itself at the Birmingham Dis- 
pensary last year, the anasarca had come on very 
suddenly, and the child completely lost all power 
of articulation, which, though he lived for several 
months afterwards, he never recovered. The 
dropsy had disappeared long before his death, and, 



ANASARCA. 



97 



from what we could learn, he died from phthisis. 
He was not, however, in Birmingham at the time 
of his death, and, consequently, no examination 
was made of the body. The pulse is frequently 
slower than in health. In a boy five years old, 
examined by Dr. Wells, it was only fifty-eight in 
a minute on the first day of the disease ; on the 
third day it became quick, and continued so 
throughout the disease. In the beginning of the 
disease the urine is always scanty, and very 
quickly becomes turbid, after it has been passed. 
Dr. Wells says, " I have in several cases allowed 
the urine in this stage of the disease to remain 
undisturbed for several hours, when it has assumed 
an appearance not hitherto observed by me in any 
other disorder. For there was at the bottom a 
very white flocculcnt matter, and above, a fluid 
of a pale white colour, and somewhat turbid ; the 
whole resembling a mixture of soft curd of milk 
and whey, when the latter has floating through 
it small particles of the curd. The patients, 
though they make but little water, have sometimes 
a frequent desire to discharge it, and in this case 
a pain is felt by them in the region of the bladder 
when it is pressed." This appearance of the 
urine is owing to the presence of the serum of the 
blood, which may easily be ascertained by boiling 
it. Sickness and vomiting are frequently present 
in this disease, but they are commonly indicative 
of affection of the brain, and always ought to lead 
to a suspicion of it. Costiveness is not more at- 
tendant upon this than many other complaints, 
but in very young children the removal of con- 
stipation frequently effects the cure of the ana- 
sarca. 

According to Dr. Wells, symptoms of extreme 
danger sometimes appear as eaTly as the third day 
after the face has begun to swell. When the dis- 
ease has continued mild for ten or eleven days, 
we never knew it give much alarm afterwards. 

The appearances of danger are various. Some- 
times they arise from an affection of the head. 

"A girl, eight years old, on the morning of the 
third day of the disease, complained of head-ach, 
which in the course of the same day became ex- 
tremely violent. In the evening she was seized 
with convulsions, which, from the report of her 
mother, continued nineteen hours, with scarcely 
any intermission. They then ceased, but return- 
ed in two hours. In this interval it was discover- 
ed that she was blind, and that her pupils were 
much dilated. The convulsions, after they re- 
turned, continued thirty-six hours ; and the patient 
remained blind eight hours after they left her. 
This child recovered. Her swellings, which were 
confined to the face and hands, disappeared while 
the convulsions were present, but returned after 
they had ceased." Dr. Wells remarks, that he 
had '■ observed dropsical swellings, from other 
causes than scarlet fever, disappear during the 
presence of convulsions." 

We have already mentioned a case where the 
articulation was suddenly lost, and Dr. Wells has 
related one in which convulsions following ana- 
sarca from scarlatina, proved fatal. 

In other cases the danger seems very clearly to 
arise from disease of the abdomen. 

" A boy seven years old, who had shortly before 
laboured under scarlet fever, was attacked with 
Vol. I.— 13 i 



dropsy, which, on the eighth day after its appear- 
ance, the first of my seeing him, occupied in a 
slight degree the whole surface of the body. The 
fever had commenced with vomiting and purging, 
and these symptoms appeared again two days be- 
fore he began to swell. On the eleventh day he 
complained much of a pain in the bowels ; vomit- 
ing and purging attacked him a third time, and 
he died in the course of the night. His stools 
were scanty and slimy." 

In the following case, which is taken from Dr. 
Crampton's Clinical Report of Dropsies, together 
with his observations upon it, the effusion did not 
certainly occur after scarlatina, but it is most clear 
that the author's opinion respecting its similarity 
to that form of dropsy which does occur after 
scarlatina, is correct. 

A pale, thin, but muscular man, who had lately 
recovered from the epidemic fever in the Hard- 
wicke Hospital, was attacked, on exposure to cold, 
with pains in his bowels, diarrhoea, and passing 
of blood ; immediately after this, ascites to a con- 
siderable degree came on, with anasarca of the 
face, legs, thighs, and scrotum ; pulse eighty, 
urine scanty and high-coloured, respiration unaf- 
fected. 

He was directed venesection to ten ounces ; 
after this his pulse was reduced in frequency, and 
the urine increased ; blue pill and cream of tartar 
were given ; his swellings very soon subsided, and 
he was discharged cured on the 10th of October. 
In this case, "the mucous membrane of the in- 
testines first showed symptoms of disease ; on the 
subsidence of this, all the serous membranes of 
the body, including all the cellular substance of 
the skin, as well as the peritoneum, being in an 
excited state after fever and exposure to cold, they 
readily took on them an inflammatory disposition, 
which soon ended in effusion.. This is the kind 
of dropsy which frequently follows scarlatina, 
measles, and small-pox : had venesection been 
resorted to in the dysenteric stage of this com- 
plaint, no dropsy would in all probability have 
ensued." 

Now, if we compare these two cases, their 
similarity will be as striking as their terminations 
were different ; nor is it difficult to account for 
this difference, since Dr. Wells, to whom we owe 
so much, though he suggested the propriety of 
bleeding in this species of the disease, acknow- 
ledges that he had never employed it ; whereas, 
Dr. Crampton's patient was bled, and the regimen 
was antiphlogistic. 

Another source of danger in the anasarca after 
scarlatina arises from effusion into the chest, 
always the consequence of preceding or accom- 
panying inflammation of the lungs. In this lose, 
the symptoms are precisely those enumerated by 
Dr. Abercrombie. 

Anasarca appears also after the measles, but 
there is no difference between it and that form 
which follows ncarlatina. The same remark may 
be made when it follows the retrocession of chro- 
nic cutaneous diseases, which is by no mean* 
rare. 

A girl, twentv years of age, had been subject 
for some months to an impetiginous affection of 
the whole body, but more particularly of the arms 
and hands, for which she at length applied to thr 



98 



ANASARCA. 



Birmingham Dispensary. After attending about 
a week, the eruption suddenly disappeared, and 
she was attacked at the same time with inflamma- 
tion of the lungs and general anasarca. She was 
bled from the arm to the extent of twenty ounces, 
with great relief to the lungs, and the blood was 
buffed and cupped. The next day the dyspnoea 
had slightly returned, and she was again bled with 
a similar result. Mercurial purgatives were given 
at the same time. It was necessary, a few days 
after, to repeat the bleeding again, from which 
time the anasarca rapidly disappeared, but she did 
not recover her breathing completely till the im- 
petiginous affection had re-appeared. 

If it be necessary to make any remark upon 
anasarca after the retrocession of these pustular 
eruptions, it would be to say, that it is, perhaps, 
more acutely inflammatory than after scarlatina, 
and usually demands more decided and active 
antiphlogistic treatment. 

Anasarca sometimes accompanies or succeeds 
urticaria. It is seldom, however, an important 
disease, and generally yields to active purgatives. 

In considering the treatment of anasarca after 
scarlatina, our first object must be to obtain an 
accurate diagnosis, both as to the nature of the 
affection, and the particular organs which are 
interested. That it is always an inflammatory 
disease may not, perhaps, be maintained without 
exception ; because we know that anasarca is as 
frequently a consequence of debility as of inflam- 
mation ; but, unquestionably, in the very great 
majority of cases its character is inflammatory. 
This, then, being decided, the particular organs 
which are affected is the next object ; and these 
are, the brain, the lungs, the heart, the liver, the 
peritoneum, &c. In whichsoever of these the in- 
flammation is present, immediate attention must 
be paid to it. Bloodletting is the first remedy 
demanded, and in almost every case this may and 
should be general. Should, however, the head be 
affected, it will be sometimes useful to apply a 
blister to the nape of the neck immediately after 
the bleeding. If we suspect the pericardium to 
be inflamed, it will be proper to apply leeches to 
the region of the heart, as well as to bleed from 
the arm ; and, indeed, this local bleeding is most 
important. Corvisart has remarked that blood 
taken from the region of the heart is much more 
efficacious than when taken from the system at 
large, and our own experience has amply confirm- 
ed the remark. It has not the disadvantage of 
producing that general and distressing debility 
which always must result from repeated venesec- 
tion. When inflammation of the peritoneum is 
present, which is easily known by the tenderness 
on pressure, the tension, and the anguish of the 
countenance, always produced by inflammation 
of this membrane, leeches in great number ought 
to be applied over the surface of the abdomen, 
and the bleeding encouraged for a considerable 
time. Recourse should be also had to fomenta- 
tions, which should be as hot as the patient can 
bear them, and be very long continued, indeed, as 
long as any tenderness remains, — supposing, how- 
ever, that this is not prevented by the application 
rtf a blister. 

In inflammation of the mucous coat of the in- 
U*tincs, which is indicated bv tenesmus, discharge 



of blood, pain in the bowels, with much flatulence, 



and aggravated during every evacuation, &C, the 
best situation for the application of leeches is the 
veree of the anus, and the quantity must be regu- 
lated by the severity of the attack and the strength 
of the patient. Sometimes vomiting is present, 
and should it not be relieved by the bleeding, it 
will be right to give some opium. In enteritis, as 
in peritonitis, fomentations are both useful and 
important. • 

We proceed to speak of the medicines which 
should be given in this disease. In every case it 
will be right to act upon the bowels, (excepting, 
however, in those cases in which diarrhoea is pre- 
sent, of which we shall speak presently,) and care 
should be taken that they be thoroughly evacuat 
ed. For this purpose we shall seldom find a bet- 
ter combination than calomel and jalap, but they 
should not be continued after the bowels are well 
opened. Sometimes individuals will be met with 
upon whom this medicine will not act as a purga- 
tive, even though frequently repeated ; and re- 
course should then be had to an infusion of senna, 
with sulphate of magnesia. When the bowels 
have been evacuated, purgatives should be sus- 
pended, and mercury on no account should be 
persevered in. The danger of persisting in mer- 
cury is so strongly insisted upon by Dr. Blackall, 
and so completely agrees with our own experience, 
that we gladly avail ourselves of his authority, 
" There are," says this enlightened physician, "no 
cases more satisfactory or more creditable to the 
practitioner, than those fevers of children with an 
oppression of the head, in which a bold use of 
calomel brings off" black discharges, and the patient 
from that moment recovers. Without inquiring 
here whether hydrocephalus is not thus cured 
which never existed, I wish to confine myself to 
that dropsy, when distinguished by the presence 
of serum in the urine ; and to state that after 
scarlatina, the tendency to this alarming conver- 
sion is increased under the use of mercurial pur- 
gatives ; that during the exhibition of two grains 
of mercury alone every night, which did not purge, 
the anasarca has disappeared, and the mouth be- 
come affected, and that there cannot be a more 
hopeless or more painful task than that of sub- 
mitting to the miserable routine of salivating such 
patients." 

When the inflammation has been subdued, and 
the bowels opened, supposing that these means 
have not been sufficient to remove the dropsical 
effusion, diuretics should be employed ; and cer- 
tainly in no disease may more perfect reliance be 
placed upon digitalis than in this. In adminis- 
tering, however, this medicine, it is of great con- 
sequence to watch its effects, and to be certain of 
the manner in which it has been dried. Some 
years ago the writer of this article employed the 
infusion to a great extent without producing any 
effects. Occasionally, perhaps, the urine might 
have been a little increased, but no change what- 
ever was caused in the pulse, although as much 
as an ounce and a half had been given three times 
a day. Surprised at this result, he at length re- 
quested to look at the dried leaf ; and, instead of 
finding it quite green, it was as black as charcoal, 
and the whole matter was explained. No eftect 
could be expected from it in such a state 



ANASARCA. 



99 



Sometimes the digitalis maybe beneficially com- 
bined with otber diuretics, particularly the squill 
and the liquor ammonia? acetatis. A very power- 
ful diuretic, also, occasionally in this disease, is 
the spiritus colchici ammoniatus ; and we have 
often succeeded with this medicine in exciting the 
secretion of the kidneys, when we had failed with 
many others. It may, however, be remarked gen- 
erally of diuretics, that they bear, and even re- 
quire, to be united together more than any other 
medicines ; and we have often thought that their 
effect has been in proportion to the complexity of 
the prescription. Thus, perhaps, when neither 
squill nor foxglove has succeeded alone, they 
have acted when united ; and it will often be well 
to join them with others. The sulphate of mag- 
nesia, when combined with squills, paregoric, and 
the liquor ammonia? acetatis, has often a very 
decided effect upon the kidneys, and either does 
not act at the same time upon the bowels, or only 
in a very slight degree. The following formula? 
have been very useful in our own practice : — 
R Liquor, ammonix acetat. £.3 ii. ; T. camphorx 
comp. f.5 i. ; T. scillx f.^i. ; Magnesix sulphatis 
3ji. ; Infusi Turaxaci f.^iv. ; a f.^ss usque ad 
{. 5 iss tertia quaque hora. R Sp. colchici ammoniat. 
f.^ii. ; Potassx subcarbon. gi. ; Infusi genistx 
f.5 viii. ; ab f.gss usque ad f.^iss tertia quaque 
hora. 

[Diuretics of the stimulating kind are not, how- 
ever, adapted for all cases of anasarca, and espe- 
cially for those that are dependent upon granular 
disease of the kidney. In ordinary cases, where 
no visceral disease contra-indicates their use, re- 
course may be had with full advantage to the infu- 
sion of juniper-berries, alone, or associated with 
the bitartrate of potassa. A solution of the bitar- 
trate may also be given for common drink ; and 
along with these a grain of squill and half a grain 
of the mild chloride of mercury may be given 
twice or thrice a day until the mouth is affected 
slightly. This course, along with the employment 
of a brisk cathartic, as the pulvis jalapa? com- 
positus twice a week, offers as well-grounded pros- 
pects of advantage in simple anasarca as any that 
could be devised. (Dunglison's Practice of Medi- 
cine. 2d edit., p. 649. Philad., 1844,)] 

When the anasarca has completely assumed a 
chronic form, and appears almost stationary, Ba- 
cher's pills are extremely valuable. In the original 
formula they contained powdered carduus bene- 
dictus, but this is perfectly inert. The formula is 
contained in Thomson's Conspectus, under the 
head " Extractum hellebori nigri." Under their 
use the effusion often gradually disappears with- 
out any extraordinary increase in the secretions. 
Occasionally they act upon the bowels, producing, 
however, tenesmus much more frequently than 
actual diarrheca ; their more manifest effect is in 
slightly stimulating the secretion of the kidneys. 
In some instances their exhibition, after a few 
days, is followed by the peculiar effects of poison- 
ing from hellebore, head-ach, giddiness, fainting, 
&c, together with irritation of the mucous coat 
of the intestines. Of course the medicine, under 
these circumstances, must be suspended ; they 
may, however, be generally resumed again in a 
lew days without any ill consequences. 

In what is connected with the treatment of this 



disease, nothing has been said of those cases in 
which the effusion is preceded or accompanied by 
diarrhoea. Where this has an inflammatory ori- 
gin, as is generally the case after scarlatina and 
other repressed eruptions, blood-letting has been 
already recommended ; and the only question that 
remains to be considered is that of purging. Now, 
though diarrhoea may arise, in the first instance, 
from simple inflammation, or irritation of the mu- 
cous membrane of the bowels consequent to the 
preceding eruption, it will certainly be maintained 
and aggravated by any accumulation within them; 
and, consequently, to take care that such accumu- 
lation has not place, is a most important duty of 
the practitioner. Here, however, he will often be 
beset with difficulties ; for should the diarrhoea be 
violent, there will be such a general exhaustion 
of the system, that to purge at once will be to 
ensure a fatal result. The mode of proceeding, 
therefore, must first be, to maintain the system by 
opiates, and this even should leeches be employed 
at the same time ; for it is a curious circumstance, 
but we believe perfectly true, that patients will often 
better bear the loss of a small quantity of blood 
than the debility resulting from severe purging. 
When rallying has occurred, it will be proper to 
regard the state of the bowels ; and if accumula- 
tion be suspected, to administer a mild aperient, 
such as castor oil, or an infusion of senna com- 
bined with some carminatives ; thus simply en- 
suring the evacuation of the intestines, without 
exciting in any violent degree the secernents of 
the mucous membrane. After the diarrhoea has 
subsided, the treatment in no way varies from that 
which has already been laid down. 

In distinguishing inflammatory from asthenic 
dropsy, much stress has been laid by Dr. Blackall 
upon the presence of serum in the urine ; but 
upon this point we have made no remark, having 
no dependence upon it as a guide of practice. 
That it is never present without inflammation is, 
perhaps, true ; but to make it really a test, the 
converse ought also to be true, viz., those dropsies 
in which it does not contain serum ought never 
to be conjoined with inflammation. This, how- 
ever, is by no means the case ; and our experi- 
ence accurately coincides with Dr. Crampton's. 
" In many of those," says this author, " which 
appeared to me to require the prompt use of the 
lancet, the urine did not coagulate. Under this 
impression, I ceased to draw any practical infer- 
ence from that appearance ;" and he adds in a 
note, " Dr. E. Percival, who was my predecessor 
as one of the physicians to the House of Industry, 
mentions that the result of his experience on this 
subject fully coincides with mine. After he had 
tried dropsical urine by the test of coagulation in 
a number of cases, he at length lost all confidence 
in the test, either as an invariable evidence of in- 
flammation, or as a guide of practice. His state- 
ment is likewise confirmed by the additional testi- 
mony of Dr. Reid, who acted as a clinical clerk 
at the House of Industry at the time those experi- 
ments were made." We would much rather, 
therefore, recommend that reliance be placed upo.i 
general symptoms than upon the state of the urine 
only, which, at the most, can only be regarded as 
an auxiliary to our diagnosis. 

The observations which have hitherto beeu 



100 



made, regard acute anasarca as an inflammatory 
disease. This, however, is not always the case. 
The following extract from Dr. Bateman's Reports 
of the Diseases of London, shows that it may be 
the result of a debilitating cause, and require a 
tonic treatment. " The patient was a middle-aged 
woman, in previous health. She was thrown into 
a state of extreme fright and alarm, on discover- 
ing in the evening that she had lost her little store 
of money, the savings of several years, and the 
next morning she was anasarcous from head to 
foot. By tonics, combined with diuretics, the dis- 
ease was speedily removed." 

The last modification of anasarca to which we 
shall advert is that in which its pathology is very 
obscure, viz., when the effusion is connected with 
disordered states of menstruation. Dr. Abercrom- 
bie affirms that such modifications of dropsy have 
been too indiscriminately classed among the ca- 
chectic diseases, and referred to a debilitated state 
of the system. 

Sauvages relates the case of a young woman 
who became suddenly dropsical over the whole 
body a few days before the menstrual period ; 
when the menstrual discharge took place, the drop- 
sical swelling disappeared. The swelling returned 
at the same time and disappeared in the same 
manner for several successive periods, till at 
length, by T a course of treatment which he de- 
scribes, it was prevented from taking place. — Sau- 
vages Nos. Meth. vol. ii. p. 471. 

Hoffmann describes the case of a woman, thirty 
years of age, previously strong and healthy, in 
whom the menstrual discharge was in general 
remarkably copious. Having suffered from a 
fright immediately before the menstrual period, 
the discharge did not take place, and she was 
seized with languor, loss of appetite, and dropsi- 
cal swelling to such a degree that the integuments 
on the feet burst and discharged serum in great 
quantity. The menstrual discharge having taken 
place at the next period, all these complaints were 
removed. — Hoff. Med. Rat. (de Hydrope.') 

Similar symptoms have been occasionally ob- 
served in connexion with suppression of hemor- 
rhoidal discharge after it has become habitual. 

Dr. Abercrombie adds, these cases certainly 
indicate a state of the system very different from 
that which we understand by the term cachexia. 
Such affections are usually treated upon the plan 
of merely evacuating the effused fluid. It forms 
an interesting subject of investigation whether 
they would not admit of much more active treat- 
ment. 

A similar affection occasionally supervenes in 
females about the period of the cessation of the 
catamenia. The anasarca comes on slowly and 
insidiously, and is in general best treated by small 
bleedings and purgatives, with restricted diet, and 
confinement to the horizontal posture. 

Excessive menorrhagia is not unfrequently fol- 
lowed by anasarca. It occasionally occurs in 
young females when the menstrual secretion is 
profuse. In these cases a considerable quantity 
of coagulated blood flows from the uterine vessels 
for the first two or three days of the menstrual 
period. Slight effusion in the lower extremities, 
and sometimes on the whole body, takes place, 
with considerable weakness. Such cases are very 



A N A S A R C A . 

hTtle under the control of treatment, unless the 
hemorrhagic action, on which the effusion de- 
pends, be checked. 

[Few topical applications arc of much benefit. 
The laced stocking, or any ordinary bandage, has 
been advised to aid absorption, and to aflord sup- 
port. When the integument becomes inflamed, 
•is it often does in cases of great distension, wash- 
es of subacetate of lead, or weak creasote water, 
may be prescribed along with the gentle support 
of the bandage ; but in most cases a warm, soft 
poultice will prove more serviceable. When there 
is apprehension of spontaneous rupture of the in- 
tegument, it may be advisable to evacuate the fluid 
by 3 punctures with the point of a lancet. Where 
the vitality of the parts has been greatly depressed 
by the protracted pressure of the fluid, gangrenous 
inflammation sometimes attacks them. To guard 
against this, the punctures ought not to be too 
numerous or too close together. As the fluid is 
discharged, a gentle and equable pressure should 
be made, by means of a bandage, on the distended 
integument. The operation of acupuncture has 
been used advantageously to drain off the fluid. 
In such cases, larger needles than those in com- 
mon use are needed. Some prefer them of the 
size of an ordinary glover's needle, and of a trian- 
gular shape, — a puncture of this kind being less 
likely to close. {Practice of Medicine, p. 651.)] 

A>*ASAItCA FROM OBGAXIC BISEASE. 

Anasarca is also a common consequence of seve- 
ral organic diseases, and its treatment admits of 
some modification according to the organ origin- 
ally affected. 

In all chronic diseases of the heart, if the pa- 
tient is not carried off suddenly, anasarca ensues 
towards the termination of life. It usually begins 
in the face, and the first symptom perceived is the 
swelled or puffed state of the eye-lids on rising in 
the morning. To this in a short time succeeds 
anasarca of the lower extremities, gradually ex- 
tending upwards, and at length involving every 
part of the body. Hydrops pericardii and hydro- 
thorax are also usually present. 

[The most common cause of dropsical infiltration 
unquestionably is, an impediment to the circula- 
tion of the blood, either in the great central organ, 
or in some portion of the venous system. Very 
frequently this impediment to the circulation in 
the heart appears to consist in a morbid condition 
of the valves, which, owing often to dilatation of 
the cavities of the heart, become insufficient to 
close the openings, and, consequently, seriously 
disturb the circulation of the blood through that 
organ. This insufficiency, as a cause of dropsy, 
would appear to exist most frequently in the tri- 
cuspid valve.] 

The treatment of anasarca dependent upon dis- 
ease of the heart must be very much guided by 
the general symptoms which may be present at the 
same time ; for it must be remembered that the 
obstruction to the flow of blood through the heart 
is very apt to produce congestion and even in- 
flammation of the lungs. If this be present, there- 
fore, an antiphlogistic treatment must of course 
be adopted. But it may also be the result of mere 
debility, and the principal inconvenience may re- 
suit from the effusion itself. The latter state 
chiefly occurs in very old cases; the former is 



ANASARCA. 



10J 



common when chronic disease of the heart oc- 
curs in young persons, and of an irritable temper- 
ament. 

The following; case exhibits the appearances 
which are frequently found in young persons, and 
affords a strong illustration of the proper mode of 
treatment. 

A young man, only thirty-two years of age, had 
suffered for two years from disease of the heart. 
A fortnight before his death, his lower extremities 
became cedematous ; he was attacked with vio- 
lent palpitations, dyspnoea, and haemoptysis. He 
was bled, and the usual remedies were resorted to ; 
but the attacks of palpitation continued to increase 
in violence, the effusion increased, and he died on 
the fourteenth day from his first confinement to 
the house. On dissection the lungs were found 
externally healthy, but generally cedematous and 
gorged with blood ; and the inferior lobe of the 
right lung was completely hepatized. The heart 
was enormous, but principally from distension of 
the right cavities. Their parietes were thinned, 
and they were at least double their usual capacity. 
The left cavities also were larger than usual, and 
the mitral and semilunar valves were in a semios- 
seous state. Both passages were greatly nar- 
rowed. 

The above case is sufficient to show that some- 
times bleeding may be necessary in anasarca aris- 
ing from disease of the heart ; but this is not the 
place to pursue farther the appearances in hydro- 
thorax with which the external effusion is usually 
united. They will more properly appear under 
that head. 

With regard, then, to the treatment of anasarca 
depending upon disease of the heart, we have first 
to consider its character. If inflammatory, or even 
attended with much congestion, bleeding will be 
very necessary ; in other cases, and where the 
principal inconvenience arises from the effusion, 
we shall derive the best assistance from purgatives 
and digitalis. In all these cases, however, we can 
only regard these medicines as capable of afford- 
ing relief: the anasarca will unquestionably re- 
turn repeatedly, unless the original disease can 
be removed. 

Of the purgatives which are recommended for 
the removal of anasarca, elaterium appears to de- 
serve the preference. As a hydragogue, indeed, 
it is not excelled. The formula which we have 
always employed, is that described by Dr. A. T. 
Thomson, viz. ss. gr. of extract of elaterium, with 
five grains of extract of gentian, given every hour 
till watery evacuations are procured ; and so suc- 
cessful has it proved, that we have never been 
tempted to change the combination. In giving this 
very powerful medicine, however, considerable 
care ought to be taken that it be not continued too 
long. In one instance, where, from the great re- 
lief which the patient had derived the preceding 
time that he had taken it, he continued it much 
longer than he was ordered, most violent hyper- 
catharsis ensued, and he became for a short time 
completely maniacal. The delirium went off 
after a few hours, and so successfully had the ela- 
terium emptied him, that a much longer period 
than usual elapsed before the effusion became 
again inconvenient. 

In order to be of much service, the elaterium 



should be repeated every two or three days for a 
fortnight, when it may generally be suspended for 
a short time. Occasionally given in this manner, 
the dropsical effusion disappears for several months, 
until it is again excited by cold or some accidental 
aggravation of the disease of the heart. 

Another remedy which of late years has been 
much recommended, is the croton oil : the chief 
objection to it is its uncertainty. Upon some in- 
dividuals a single drop acts very violently, while 
upon others it appears to be perfectly inert. We 
have given as many as five drops to one patient, 
of the same preparation which caused upwards of 
thirty large watery evacuations in another patient 
who took only a single drop. When it does, 
however, agree with the constitution, it is in some 
respects preferable to elaterium, as the patients 
sooner overcome its debilitating effects. 

It often happens that with disease of the heart 
some disease of the liver is combined ; and here 
mercurial purgatives, joined with diuretics, are fre- 
quently very useful During the last year we suc- 
ceeded in removing the dropsical effusion by a 
powder of calomel and jalap every morning for a 
fortnight, giving diuretics at the same time, when 
elaterium had only afforded very temporary relief. 

Sometimes the dropsical effusion is attended 
with great debility and hysterical symptoms ; and 
this will admit neither of bleeding nor purging. 
Here the ferri et potassae tartras combined with 
some mild tonic may often be employed with great 
advantage. The tartarized iron acts slightly, 
sometimes indeed freely, upon the kidneys, while 
its tonic powers support the general strength of 
the system. Occasionally this medicine may be 
beneficially used after slight bleedings, especially 
in those cases in which congestion and not inflam- 
mation is present. 

Some practitioners place very great reliance 
upon digitalis, and certainly its effects are some- 
times quite marvellous. We shall only remark 
upon it, that no medical man should prescribe 
digitalis without visiting his patient every day ; as 
from its tendency to accumulate in the system, 
without this precaution it may often prove fatal. 

Organic disease of the uterus, attended by he- 
morrhage, is occasionally followed by anasarca 
The following case will illustrate this form of 
dropsy. 

A married female, thirty-six years of age, suf- 
fered, for three years before death, from cauli- 
flower excrescence of the uterus, attended with 
profuse hemorrhage at intervals. Some time after, 
she became anasarcous. The effusion continued 
to increase so long as the hemorrhage recurred. 
When this ceased, she took large quantities of 
bark, and generous diet was allowed : the effusion 
disappeared, and she regained her strength. 

[Another cause of anasarca, and of dropsy of 
the cavities, is the disease of the kidney, described, 
of late years, as the disease of Bright. In all 
works on the practice of physic, suppression of 
urine, or a sudden diminution in the quantity of 
the secretion, has been esteemed a cause of ana 
sarca ; but the researches of modern observera 
have shown, that a pathological condition of tho 
kidney, in which the cortical portion assumes a 
granular character, and secretes aibumen from tho 
blood, is by no means an uncommon cause. Tht< 



102 

characters of this renal affection are described 
elsewhere. 

Of partial dropsies, resulting from temporary 
obstructions of the circulation, a familiar example 
occurs in intermittents, in almost all cases ot which 
there is more or less enlargement of the spleen. 
and concomitant infiltration of the cellular mem- 
brane ; but both affections pass away after the 
intermittent has been arrested. 

On the examination of the subcutaneous cellu- 
lar tissue of one who has died of anasarca, it is 
found distended by a limpid serous fluid, usually of 
a bright orange-yellow hue. In the most common 
cases of asthenic anasarca, it bathes the cellular 
tissue and the subjacent muscles, which are ren- 
de,ed unusually pale and flaccid, and tear with 
the greatest facility. Sometimes the infiltration 
is confined to the subcutaneous cellular tissue ; 
but at others it extends to that which envelopes 
the fasciculi and the fibres of muscles, the ten- 
dons, vessels and nerves, and occasionally to that 
which enters into the constitution of the viscera. 
Wherever the infiltration exists, the cellular mem- 
brane is much softened. (Dunglison's Practice 
of Medicine, 2d edit., p. 647 : Philad., 1844.)] 

Local anasarca. 

Anasarca may either generally or locally at- 
tend upon organic disease of any part of the body ; 
but it scarcely seems necessary to consider these 
more particularly. We shall now, therefore, pro- 
ceed to consider those forms of effusion w hich are 
confined to the lower extremities, and in many 
instances do not even extend above the knee. The 
first place is due to phlegmacia dolens, which 
must be regarded as a local anasarca. 

The pathology of this disease formed for many 
years a stumbling-block to medical men ; and se- 
veral very recondite theories were set forth upon 
the subject. The investigations of Dr. D. Davis, 
and ether pathologists, at length appear, however, 
to have set this question at rest, and to prove satis- 
factorily that " the proximate cause of phlegmasia 
dolens consists in a violent and destructive inflam- 
mation of the iliac veins and their contributorics, 
including in some cases the inferior portion of the 
vena cava." 

Dr. Kobert Lee has entered more minutely into 
the pathology of phlegmasia dolens, and has en- 
deavoured to prove that it is connected not only 
with inflammation of the femoral veins, but of the 
uterine veins likewise. 

Phlegmasia dolens is occasionally also in the 
male, as in the female subject, in idiopathic disease. 
A short time ago the writer of this article was called 
to a man, twenty years of age, a carpenter by 
trade, who, after an attack of catarrh, was suddenly 
seized with very exte.nsive cedema of the right leg 
and thigh. The femoral vein could be distinctly 
'raced, as a firm, hard chord, very tender to the 
touch, from the groin to its passage through the 
t?ndon of the triceps. There were typhoid symp- 
toms present at the same time. The oedema of 
the limb was very much reduced by the applica- 
tion of leeches, and eventually the man recovered ; 
the treatment after the first few days being chiefly 
constitutional. 

In the treatment of anasarca attendant upon 
ncute inflammation of the veins, our first atten- 
Mon must obviously be paid to the local afli 



A X A S A RCA. 

~,d the application of 1,-cchcs in the course of the 
vessel is a most important point At the same 
time recourse should be had to purgatives, and 
more particularly to mercurial purgatives. It by 
these means we succeed in removing or greatly 
diminishing the febrile state, we shall still have 
to combat the disease in its chronic form, for it 
scarcely ever happens that recovery is at once 
complete. 

If we look to tho appearances which the af- 
fected vessels exhioit upon examination after 
death, we find them generally more or less loaded 
with coagulable lymph, sometimes also accompa- 
nied by pus. From what we know of the great 
irritability of the veins, and the consequences of 
injecting' pus into their cavities, we may well 
question if recovery be ever possible when suppu- 
ration has occurred within them ; and it will be 
therefore the deposition of coagulable lymph only, 
in the chronic form of the malady, that we shall 
have to overcome. Analogy teaches us that that 
kind of inflammation which gives rise to the effu- 
sion of plastic lymph is most easily subdued by 
mercurv. It is this which occurs in iritis, which 
affection is frequently first manifested to the prac- 
titioner by the cloudiness induced by the presence 
of coagulable lymph ; and in this disease mercury 
almost deserves the name of a specific. It is nearly 
as serviceable in that chronic state which remains 
after an acute attack of phlegmasia dolens ; and 
we have frequently found the compound calomel 
pill, given every night for two or three weeks, 
make a very material improvement in the state of 
the limb. It may also be advisable, at this period, 
to combine it with mild tonics. It too often hap- 
pens, however, that some stiffness and swelling 
will remain during life, whatever may have been 
the treatment employed. In the latter stages of 
the complaint, frictions are very useful. 

We have entered on the subject of phlegmasia 
dolens with the view of rendering the pathology 
of the various forms of anasarca as complete as 
possible. For a more ample account of this im- 
portant subject, we refer the reader to the article 
Phlegmasia Dolens. 

There is also an acute species of anasarca oc- 
curring in children, generally about three or four 
years old, and confined to the legs, seldom extend- 
ing above the knee. It does not appear usually 
united with any organic disease, and is generally 
attendant upon that febrile state to which children 
of this age are so liable from affections of the 
prima? via?. Sometimes it is accompanied with 
diarrhoea. It commonly disappears under the 
treatment employed for the cure of the original 
disease. 

Local anasarca occasionally accompanies some 
cases of amenorrhoea, and varies from mere cedema 
of the ankle to extensive effusion reaching some- 
times as high as the groin. This affection, how- 
ever, is not always attended with amenorrhoea. 
but may occur when the catamenial discharge is 
not manifestly disturbed. The first symptom is 
swelling and pain about the ankle, more particu- 
larly troublesome towards night. In many of 
these cases, examination of the veins of the extre- 
mity will detect tenderness or hardness, some- 
where in the course of the great veins and we 
have seen one instance where the symptoms above 



ANASARCA — ANGINA PECTORIS. 



10.3 



enumerated wore the only symptoms present. The 
spot most usually tender is just, where the femoral 
vein parses into the ham, and the affected part 
often does not exceed more than an inch in length. 
Frequently also the vein may he felt in this place 
rolling like a chord under the finger. A lady ap- 
plied to us in January, who complained of slight 
pain and swelling at the ankles at night. There 
did not appear to be any other affection. The 
general health was good, and the catamenia were 
regular. There was tenderness and hardness of 
the femoral vein in the spot alluded to above, but 
more in the left than in the right thigh, the ankle 
of which limb was more swelled than the other. 
Some leeches were applied, which removed both 
the tenderness and hardness of the veins; and the 
ankles never swelled after the bleeding. We heard 
of her a few weeks afterwards, and she had had no 
return. 

The following case, however, affords an exam- 
ple of the most frequent form of the disease, and 
it is one of many in which the same tenderness 
of the veins has been exhibited, and which have 
yielded to the same treatment. 

A young lady, aged twenty-two, had long suf- 
fered from hysteria and its various complications, 
gastrodynia, flatus, &c, great debility, and de- 
pression of spirits. The catamenia were always 
scanty. Her legs began to swell about the ankles, 
and the swelling gradually extended to the pelvis. 
There was considerable tenderness in the course 
of the femoral veins. Twenty leeches were ap- 
plied to the affected part, with the effect of dimin- 
ishing the swelling ; but some tenderness in the 
course of the femoral veins remained, so that 
leeches were again applied. After this the swell- 
ing of the limbs was still further diminished, and 
there was scarcely any tenderness in the course 
of the veins. A month afterwards the oedema had 
nearly disappeared. She remained some time 
under treatment for dyspeptic symptoms, with, 
which Ihe cedpma was combined, but no return 
of the effusion to any extent was observed. In 
this, however, as in most of these cases, the ankles 
continued to swell at night in a greater or less 
degree, but the oedema did not extend much higher. 

It is Tiot always that this kind of effusion can 
be traced to obstruction in the veins. There are 
some Ieucophlegmatic females in whom no local 
affection can be discovered to account for the 
oedema, and in whom it seems simply the effect 
of general debility. In cases of this nature, the 
mistura ferri composita is frequently very bene- 
ficial. The best mode of giving it is in combina- 
tion with decoction of aloes, or some mild ape- 
rient. In all these cases reference must of 
course be had to the accompanying symptoms. 
It would be idle to lay down any positive rules 
for the treatment of the anasarca merely. 

There are. doubtless, other forms under which 
anasarca sometimes appears, besides those which 
have been now enumerated. Enough has, how- 
ever, been done to exhibit the principles upon 
which effusion should always be viewed, that is, 
not as a disease in itself, but as an evidence of 
some disturbance in the functions of the animal 
system, or upon some actual change in the struc- 
ture of some important organ. 

J. Darwall. 



ANGINA PECTORIS. The affection thus 
commonly designated has attracted great attention 
since it was first formally noticed by Dr. Heberden, 
about sixty years ago.* The name above prefixed 
was given to it by the author just mentioned, on 
account of its " seat, and the sense of strangling 
and anxiety with which it is attended ;" the word 
angina (from «yx«, strangula) having been ap- 
plied by the ancients to all diseases of the throat 
accompanied by a feeling of suffocation or stran- 
gulation. (Celsus, lib. iv. cap. iv.) The word 
is still used in this sense by the French, Germans, 
and other continental nations, comprehending all 
the inflammatory affections of the fauces, larynx, 
trachea, and neighbouring parts, classed by Dr. 
Cullen under the head Cynanche. It is evident 
from the expressions above quoted from Dr. Heber- 
den, that he adopted the name in common use, 
qualifying its new application by the addition of 
the word pectoris. It is, therefore, incorrectly 
said by Dr. Frank, that this name has nothing in 
common with the same word as applied to affec- 
tions of the throat.-(- This author derives the 
term from the Latin verb angere, taking this in 
its more general or metaphorical sense, as signify- 
ing to occasion distress, and apparently forgetting 
that this word is itself derived from o-YX^' allt '> nl 
strictness of language, means the same thing. As 
the word angina has ceased to be applied, in the 
medical language of this country, to inflammatory 
affections of the throat, we shall adopt its use in 
the present article without always retaining its 
qualifying adjunct -pectoris. 

Angina can boast of a very copious synonymy. 
The following are the principal names by which 
it has been designated by different writers, and the 
order of their imposition : — 

Cardiogmus cordis sinistri Sauvages, 17t>3 

Angina Pectoris Heberden, 1768 

DieBrustbriiu ne Eisner, l?t-0 

Diaphragmatic gout Butter, 1791 

Asthma Arlhriticum Schmidt, 1 

Syncope Angens Parry, 

Asthma Dolorificum Darwin, 

Sternodynia Syncopalis Sluis, 

Astlnnaspaslico-arthriticum incon- ) g toe ]j er 

stans S 

Suspirium cardiacum Stephen, 

Sternalgia ISaumes, 

Stenocardia Brera, 

Pni»opln)hia Swediaur, 18J2 

Angor Pectoris Frank, 1818 

[Neuralgia of the heart Hope, 1832] 

Although the above catalogue does not go far- 
ther back than the time of Sauvages, there can be 
no doubt that the complaint was well known to 
practical men from the earliest periods of physic ; 
but like several other affections now classed under 
particular names, and regarded as distinct dis- 
eases, it was merely considered as a symptom, or 
isolated group of the ordinary symptoms, or as an 
accidental complication or particular phasis of 
some known disease ; and, if noticed at all, passed 
under the usual name. Before the time of Dr. 
Heberden, indeed, Sauvages, after Poterius, cer- 
tainly noticed and named the affection as a sepa- 
rate form of disease ; but of this fact Dr. Heber- 
den was ignorant ; and his much fuller and moie 



17i>9 
1801 
1802 



1804 
180G 
1810 



* Some Account of a Disorder of the Breast. Read at 
the College, July 21, 1768. Medical Trans, vol. ii. p. 59. 

f Hoc vocabulum nihil commune habet cum ec av^intr, 
sub quo faiicium inflammatio vulgo intel'vgitur. JV'.r 
Med. l-'niv P. ii. vol. viii. p. 2-14. 



104 



A .\ G I N A PECTORIS. 



accurate history justly entitles him to the honours 
of an original observer. Many passages in the 
writings of the ancients, and particularly in those 
of Hippocrates, might, without much straining, be 
made to apply to this disease, notwithstanding the 
round assertion of the last named author, that 
" the heart is a dense and solid body, and there- 
fore unsusceptible of pain."* Some have imagined 
that Areteus referred to angina under the name 
of ir rai/ifitaj ; but his account is much less charac- 
teristic of the affection than many passages in the 
writings of Hippocrates. The account which 
Aretasus gives of the second species of angi?ia 
comes much nearer the disease which we have to 
describe under the same name. (Arttxi Opera, 
p. 7. Oxon. 1723.) In the works of Cslius 
Aurelianus, a brief statement occurs in his chap- 
ter on paralysis, which has been generally con- 
sidered, and apparently with reason, as referring 
to the disease now under consideration.f The 
case of Seneca, as described by himself, has also 
been generally considered as a case of angina, and 
we think most justly. He terms his disease sus- 
pirium. (Senecas Opera, t. ii. p. 136. Epist liv.) 
In perusing the medical writings of the sixteenth 
and seventeenth century, we meet with many 
observations which can only apply to this disease. 
These are most commonly found in their account 
of asthma, with which, as a well-known disease, 
and as having some of the external symptoms 
somewhat similar, it was most likely to be con- 
founded. It was with this disease, or at least with 
dyspnoea, that it was confounded by Poterius and 
Barteletti, certainly the first medical writers who 
notice the disease in such terms as cannot be mis- 
taken. + In the works of Hoffmann and Mor- 
gagni, many well-marked cases of angina will be 
found. § One of the earliest, probably, and cer- 
tainly one of the most unequivocal cases of angina 
to be found in the English language, is that of the 
lather of the great Lord Clarendon, recorded by 
his son. In this case the event was fatal. || 

After the publication of Dr. Heberden's paper, 
the disease was noticed by a vast number of medi- 
cal writers in England, France, Germany, and 
Italy, both in periodical publications, in the trans- 
actions of societies, and in distinct treatises. Since 
it first attracted attention, angina seems, indeed, to 
have been a favourite with the profession, and the 
mere catalogue of the published cases and mono- 
graphs would fill many pages. The reader who 
is curious in this matter is referred to the writings 

* Est cor res solida ac densa, et propterea dolore non 
aflligitur. De Morb. lib. iv. cap. x. 

f Erasi stratus memorat paralyseos genus et parndoxon 
appellat, quo ambulantes repente sistuntur ui ambulare 
■ion possi nt, ft turn rursum ambulare sinuntur. Citron. 
ib. ii. c. i. p. 348. 

% Quffidam est respirandi difficultas (says Poterius) 
quffi per intervalla deambulantibus accidit. In hac fit 
pra?ceps virium lapsus, propinquis tenentur niti adraini- 
culis, alias humi corruerent; hi ut plurimum derepente 
inoriuntur. Pet. Porter. Op Om.cum Annot. Hoffmann. 
p. 30 C J. Franco/, ad Main. 1098. Fabricius Barteletti, in 
his MeUwlus in Dyspnaam, (Bonon. \K\i) speaks of a 
variety of this affection, •' qua; in ambulations motu 
srumpens sola quiete mitescit." 

§ A single case selected from the works of each of these 
authors suffices to prove that they were well acquainted 
with the disease. See Hoffmann. Consult. Med. Cas 
83. Op. t. iv. p. ]£;. Mergagni de Sed. et Cans. Morb! 
lib. n. epist. xxvi. art. 31. 

l| Life of Edward, Earl of Clarendon, (dated July 1C68 ) 
Orford, 17(31, vol. i. p Jb. ' 



of Butter, Parrv, Black, Blackall, Eisner, Stoeller, 
Jahrt, Dcsportcs, Jurine,Brera,and Zecninelu. In 

the work of Zechinelli, in particular, a most ample 
collection of the recorded facts and opinions 
respecting this disease will be found ; although 
even his industry has failed to notice a consider- 
able number of important cases scattered through 
the medical literature of this and other countries. 
(Sulla Angina di Petto. Padova, 1813.) 

History of the Disease. — Angina pectoris 
is a disease of an intermitting character, in which 
the patient has intervals of comparative ease or 
of perfect health, between paroxysms of greater or 
less suffering. The paroxysm usually makes its 
first attack while the patient is taking exercise. 
Whilst walking or running, and more particularly 
if in the act of ascending an elevation at the same 
time, he is all at once seized with a most distress- 
ing sensation in the chest, usually in the region 
of the heart, or about the lower half of the ster- 
num and towards the left side. This sensation is 
variously described, as a pressure, or stricture, or 
weight ; or as a positive pain of various character 
and degree, sometimes obtuse, sometimes acute, — 
tearing, burning, or lancinating. There seems 
always to be something peculiar in the pain, 
whatever be its degree, unlike the pains of other 
parts of the body, and as if it were combined 
with something of a mental quality. There is a 
feeling and a fear of impending death ; and the 
primary symptoms of corporeal disorder are speed- 
ily modified by the consequences of mental im- 
pressions conveyed through the nervous system.! 
The patient makes a sudden pause, eagerly catches 
hold of whatever is next him for support, perhaps 
raises the hand to some object above him to which 
he clings, or, it may be, imperceptibly sinks down 
on a chair or bank, as if unable to stand, yet afraid 
of the movements necessary to seat him. The 
face is pale, the expression of the countenance 
haggard, the whole body is covered with a cold 
sweat, and death appears to be impending no less 
to the inexperienced spectator than to the miser- 
able patient. Such, in fact, is sometimes the ter- 
mination of the paroxysm, but rarely, and scarcely 
ever in the early stage of the disease. After 
suffering in the way described for a longer or 
shorter period, varying in different cases from a 
few minutes to one hour or more, the patient 
revives, sometimes gradually, sometimes suddenly, 
and in many cases immediately resumes the feel- 
ing and the faculties of health. 

The pain is rarely confined to its primary and 
principal site in the cardiac region, but increases, 
in different instances, very variously both in direc- 
tion and extent. It shoots upwards or downwards, 
or to the right side, and almost always through the 
left side of the chest towards the" shoulder and 
axilla, and very frequently into the left arm about 
the middle of the humerus, or as low as the elbow. 
Sometimes the pain in the last named places is 
extremely acute ; and, frequently, sensations of a 
similar kind, though less severe, are experienced 
all along the arm to the fingers, or in both arms, 
or along the throat and side of the face, and occa- 
sionally even in the lower extremities. Generally, 

U •' Quidni ?" exclaims Seneca, reflecting on his own 
sufferings from this disease, " aliud enim quidquid Ml 
Jjgrotare est ; hoc est animam agere." Epist. liv 



ANGINA PECTORIS. 



10f> 



these pains in the limbs accompany or succeed 
that in the chest; sometimes they precede it. In 
most cases the respiration is unimpeded, although 
the patient seems at times as if he were unable or 
afraid to breathe. At other times, and perhaps 
more generally, deep inspirations are made, and 
are aided by raising the arms and shoulders, with 
the view of enlarging the chest as much as possi- 
ble. Sometimes the breath is retained for a con- 
siderable time. 

The pulse is found to vary considerably in 
different cases. Sometimes it is regular, some- 
times irregular; in one patient frequent, in another 
slow ; sometimes feeble, sometimes strong, and 
occasionally altogether suppressed ; most com- 
monly, perhaps, it is regular, small, and weak. 
Eructations of flatus are almost always present, 
and when present generally afford relief. Fre- 
quently, indeed, in the less severe cases, the parox- 
ysms seem to give way immediately upon the 
supervention of the discharge ; and the same 
result occasionally follows, but much less com- 
monly, a similar discharge downwards. In the 
commencement of angina, the attacks are, in gene- 
ral, comparatively mild ; and commonly increase 
progressively in severity as well as frequency, as 
the disorder is prolonged. In a certain proportion 
of cases, the symptoms are so mild as to give rise 
to doubts whether the affection is really angina ; 
the whole paroxysm often consisting of an instan- 
taneous pang in the situation of the heart, passing 
off nearly as soon as felt. In others, the pain is 
of longer duration, and is accompanied by more or 
fewer of the irradiations to remote parts which 
mark the severer paroxysms, — in particular, the 
pain of the left arm. In a third class of cases, the 
patient is suddenly invaded by an indistinct, very 
distressing, but not very painful oppression in the 
region of the heart. He is agitated and alarmed ; 
his sensations are distressing, his apprehensions 
are more. so. He feels as if the heart were vio- 
lently compressed ; or as if it were distended and 
about to burst, or as if its movements were sud- 
denly arrested. This last sensation is the most 
common. In every variety of paroxysm, whether 
slight or severe, palpitation of the heart is not an 
unusual occurrence. Sometimes it precedes, some- 
times accompanies, sometimes follows the painful 
sensation ; but in many of the severest and best 
marked cases it is entirely wanting. 

Angina occurs in both sexes, and at all ages 
above that of mere childhood ; but it is much 
more common at particular periods of life ; and 
the severer cases, at least, are met with much 
more frequently in the male sex. Of eighty-eight 
cases related by different authors, and to which we 
hue referred with a view to this particular ques- 
tion of sex, only eight occurred in females, being 
exactly one-eleventh of the whole ; and of the 
total number of patients, twelve only were under 
ntty years of age. Were we, then, to be guided 
solely by the published cases, wc should say that 
the common opinion, which represents the disease 
is especially affecting the male sex and persons 
advanced in life, is most just. No doubt it is so; 
but still it is necessary to make some allowance 
for circumstances connected with these recorded 
eases, before they can be received as grounds for 
fixing the statistics of the disease, taken without 
Vot. I 14 



reference to its degree of severity. The truth 
seems to be, that of the more severe cases, particu- 
larly such as depend on organic disease of the 
heart and large vessels, the groat majority occur in 
the male sex ; while of milder eases, a very con- 
siderable proportion, perhaps an equal proportion, 
are met with in females, and at an earlier period 
of life. This, at least, is the result of our own 
experience ; and the same opinion is entertained 
by writers of great authority.* The same conclu- 
sions as to the greater frequency of mild cases in 
the female sex, and at an earlier age, are supported 
by certain other results of the published histories 
of angina. Thus, while only one-eighth of the 
males recovered, no less than one-half of the 
females did so, viz., four out of eight ; and of 
these four, only one was above fifty years of age. 
But it is to be further recollected that the greater 
mildness and curability of the disease in women 
will partly account for the very small proportion 
of this sex among the published cases. The very 
severe cases naturally attract mor • attention, more 
particularly if, as often happens, they have been 
terminated by a sudden death, and followed by a 
dissection ; and these are the cases that are usu- 
ally recorded and published ; while others of pre- 
cisely the same nature, but differing in degree, are 
too often overlooked or even forgotten. From 
these considerations, therefore, and from our own 
observations, corroborated by those of Jahn, Ho- 
sack, Laennec, &c, we are disposed to believe, 
that while among the severe examples of the dis- 
ease, the proportion of males to females may be 
even greater than is commonly believed ; among 
the milder cases, theie may be found as many 
women as men. 

There is no situation in life peculiarly exempt 
from this disease ; but it attacks some classes of 
persons much more than others. Like many other 
diseases, angina is the attendant rather of ease and 
luxury than of temperance and labour ; on which 
account, although occurring among the poor, it is 
more frequently met with among the rich, or in 
persons of easy circumstances. This fact alone 
shows that its attacks are much more influenced 
by adventitious circumstances than by natural 
temperament. The same remark applies to the 
reported prevalence of the disease in particular 
seasons, and in what has been termed particular 
medical constitutions. (Laennec, De l'Auscult. 
Med.) It must, however, be admitted that the 
greater number of cases depend on causes of loo 
fixed and too formidable a quality to be modified 
by circumstances of this kind. 

Although by no means of rare occurrence, an- 
gina cannot be said to be a common disease, more 
particularly in its strongly marked form. In the 
numerous instances of organic disease of the heart 
constantly met with in practice, symptoms which 
may be termed irregular angina, namely, morfc or 
less of pain or uneasiness in the region of (he 
heart, suddenly coming on during exercise, and 
obliging the patient to stand still for a short time, 
are complained of, in almost every case, in a greater 
or less degree ; but the severe affection described 
by Dr. Heberden and his followers, and of which 
an outline has been given in the beginning of this 

* Jahn, Ueber die Syncope Anginosa Parry. Hufo 
land's N. Journ. 1806. 



106 



ANGINA PECTORIS. 



article, is certainly not of frequent occurrence. It 
is proper to observe, however, that the great im- 
provements which have taken place of late years 
in pathology, hy enabling practitioners to connect 
symptoms with their organic causes more accu- 
rately, have necessarily diverted the attention from 
the artificial combinations of the old nosology ; 
and as the knowledge of cardiac affections has, 
moreover, been particularly increased by the dis- 
covery of a very superior instrument of diagnosis, 
it is probable that many cases which the older 
authors would have referred to angina, have of 
late years been looked upon and recorded simply 
as diseases of the heart. If only the well-marked 
cases are taken, it will be found that the whole 
number recorded in the works of our English 
writers since the time of Heberden, as well as in 
those of the best authorities in France, Italy and 
Germany, does not much exceed one hundred. 

If we were to form our opinion solely from the 
results of the published cases of angina, we should 
say that it was one of the most dangerous and 
fatal of diseases. For instance, in a list of sixty- 
four cases now before us, of which the result is 
recorded, no less than forty-nine proved fatal, 
almost all suddenly ; while of the remaining fif- 
teen the greater proportion are recorded as relieved 
only. But we are by no means disposed to receive 
such results as coming at all near the truth, as 
regards the disease generally. Most of the cases 
in the above list were examples of organic disease 
of the heart or large vessels ; and if we were to 
limit our views to this class of cases, the propor- 
tion of deaths above stated is probably less than 
the truth. But we shall find that a very large 
eloos of cases, legitimately ranged under the head 
of angina, have no necessary dependence on struc- 
tmal lesion of the heart ; and of these the general 
result will be found very different from that re- 
corded above. It is from having overlooked this 
lant class of cases, that most of the earlier writers 
on angina considered it as almost inevitably fatal ; 
and it is, perhaps, from giving too exclusive an 
attention to the milder forms of the affection, that 
some other authors have taken a view of it per- 
haps as much too favourable as the others did the 
reverse. Of the latter class of writers, Laennec, 
Hosack, and Butter are the principal. Laennec 
considered the disease as extremely common in its 
milder forms, and did not regard it, in general, as 
a KJvere disease. (Loc. Cit.) Dr. Hosack believes 
the severity of the affection to have been much 
ej iggcrated, and looks upon it as very much under 
the influence of medical treatment.* Dr. Butter, 
who considered angina to be a species of irregular 
gout, says that he must " impute the chief, if not 
the sole, difficulty of curing the disease to the 
want of conformity of the patient himself with 
regard to diet."-)- 

The following synoptical view of some of the 
statistical details relating to angina will be found 
convenient for reference, and is, therefore, sub- 
joined, although in some respects a repetition of 
what has gone before. 

A . Results relative to the sez of the patients. 

Totul number of cases examined. gg 

Of these were, men gO 

women a 



* Essays on various Si-bjects of Med. Sei., vol ij 288 
T Treatise on Angina Pectoris, 2d edition p. 24. 



B. Results relative to the age of the patients. 



Total number whose ages are recorded, 

Of these were, above fifty 

under fifty 



.64 



C. Results relative to the event of the cases generally. 
Total number of patients, the event of whose cases is 

recorded, '■'■;;'".';";'' 

Of these there died (almost all suddenly). .49 

Were relieved or recovered 15 

D. Results relative to the event of the cases as regards sez. 

1. Total number of fatal cases -iO 

Of these were, men 47 

women 2 

2. Total number of cases cured or relieved, 15 

Of these were, men 11 

women 4 

Causes* Under this head, we shall at present 

notice only the exciting causes of the paroxysms. 
The remote and predisposing causes will be con- 
sidered with more practical advantage, athough 
with less logical catenation, when we come to treat 
of the different varieties of the disease, and the 
means of preventing and curing it. 

The exciting causes of the paroxysms of angi- 
na, or the circumstances under which they occur, 
are, in general, so well marked, and so constant 
and uniform, that they might almost have been 
included in the description of the disease. They 
may be stated in general terms, to be all such as 
accelerate the flow of blood, or suddenly increase 
the action of the heart. The principal of these 
circumstances are all kinds of bodily exercise, as 
in walking, running, straining, &c, and the more 
powerful emotions of the mind. Of all the move- 
ments of progression, that of going up stairs or 
up hill is by far the most effective in inducing a 
paroxysm ; and it has been frequently remarked 
that, ceteribus paribus, walking against the wind 
is considerably more injurious than walking in a 
contrary direction. Sometimes even walking in 
the open air in perfectly calm weather has induced 
a fit, when the same degree of exercise within 
doors has had no such effect. (Medical and Phy- 
sical Journal, vi., p. 320.) In some rare instances, 
the first paroxysm has been induced suddenly 
during powerful bodily exertion, as in leaping, 
raising a weight, &c. ; j and in such cases, it has 
been found that a slight rupture has taken place 
in the valves of the heart or their appendages. In 
the earlier stages of a severe disease, and through 
the whole course of mild cases, the attacks are 
commonly induced by the more powerful ol the 
causes mentioned, or by others of an analogous 
kind ; but as the disease increases in severity, the 
slighter causes of the same kind suffice to excite 
a paroxysm. Thus, in some unhappy individuals, 
almost any .general bodily movement, such as the 
act of turning in bed, or walking across the room, 
or coughing, sneezing, or relieving the bowels, or 
even thinking intensely, will occasion a seizure 
In subjects of such extreme susceptibility, parox- 
ysms will, of course, frequently occur without 
any very obvious cause. Any of the causes being 
applied immediately after a meal, acts with much 
greater certainty and force ; and sometimes the 
mere presence of a full meal in the stomach seems 
sufficient to excite a paroxysm. In certain cas> 
the attacks occur most frequently at ni^ht, on th« 
patient awaking from sleep, as is so frequently the 

t Black in Mem. of Med. Society of London iv P B. 
Blackall on Dropsy, 2d edition, p. 3g.] t ' 



ANGINA PECTORIS. 



107 



case with paroxysms of asthma ; and this circum- 
stance is one of several which have led some 
writers to consider angina as allied to that disease. 
Pathology of Angina. — In a perfect system 
of philosophical medicine, founded on the basis of 
the pathological condition of the organs primarily 
affected, angina, such as we have described it in 
the preceding pages, would be banished from the 
list of individual diseases ; since it cannot be 
denied that the various phenomena which consti- 
tute the paroxysm may be present in different 
states of the system, or may even originate, as far 
as we know, in different states of the very organ 
in which we believe them to have their site. In 
such a system, it could only be regarded as a 
group of symptoms — frequently found co-exist- 
ing, it might be — but still merely the incidental 
attendants of different diseases. But as it is im- 
possible, in the imperfect state of our actual know- 
ledge, to say, in the case of angina, as in that of 
so many other diseases, what morbid phenomena 
are essential, and what merely contingent, we 
shall attempt no such refinement on the present 
occasion, but following the steps of our numerous 
predecessors, shall treat of angina as a distinct 
disease. 

In common language, the term angina pectoris 
is frequently restricted to the more prominent 
phenomena of the paroxysm, as above described ; 
and there can be no harm in so applying it, pro- 
vided its restricted meaning is not misunderstood. 
But when the disease angina is regarded in the 
comprehensive point of view which can alone lead 
to important practical results, it is very far from 
being confined to the limits of the paroxysm. On 
the contrary, it must be considered as compre- 
hending all the derangements of the system, gen- 
eral and local, which precede, accompany, or fol- 
low the paroxysm, or which can in any way be 
regarded as influencing it. This is the notion of 
the disease which exists in the mind of every ex- 
perienced practitioner ; and this is the sense in 
which the word angina is generally to be under- 
stood in the present article, although it will be 
observed that we have already been using it in its 
more restricted meaning. 

Seat and nature of the disease. — Numer- 
ous considerations prove that the pain in the 
paroxysm of angina has its primary and principal 
seat in the heart or annexed great vessels. 1. The 
patients almost always refer their agony to the 
region of the heart ; the more distant pains of the 
shoulder, arm, &c, appearing to spring from this 
primary source, and being, in almost every case, 
subsequent to the invasion of the paroxysm.* 
2. The peculiar character of the patient's suffer- 
ings, partly physical, partly mental, the anxiety, 
dread, &c., are such as could only be produced by 
the affection of an organ like the heart, on whose 
action life so immediately depends, and whose 
disturbance is so instantly perceived by the sen- 
sorium. 3. The exciting causes of the paroxysm 
are always such as are especially calculated to dis- 



* In a few cases the pain , <is been found to commence 
in the arm, and dart from ti -s to the breast. But we 
believe this lias always been in rases of Ion? standing. 
We are aware of no case of recent origin in which such 
an occurrence lias been observed. And this distinction 
is import an 



turb the natural action of the heart ; namely, 
bodily exertion, emotion of mind, compression of 
the heart by the encroachment of other organs, 
&c. 4. The frequently fatal termination of this 
disease, and the suddenness of the death, are only 
to be explained by disorder of the heart or great 
vessels, as the affection of no other organ in the 
chest or abdomen could produce such a result. 
5. But all these presumptive proofs, if we may so 
term them, are corroborated, and, indeed, confirm- 
ed, by the physical condition of the heart itself, 
ascertained by dissection in fatal cases, and by the 
stethoscope during the life of the patients. In a 
vast majority of the fatal cases of angina of which 
dissections are recorded, there has been found 
great structural disease in the heart, or aorta, or 
both. In these cases, there can scarcely be a 
doubt entertained that the pain was seated in the 
heart or great vessels ; and as the character of the 
pain and other symptoms in cases in which no 
organic lesion is recorded, have been observed to 
be precisely similar to those occurring in the 
former, it would seem unjustifiable scepticism to 
disbelieve that both had the same site. There 
seems nothing improbable, much less impossible, 
in a heart altogether of healthy structure becom- 
ing the site of such a pain ; but there is reason 
to believe that, in the few cases of fatal angina 
in which no organic lesion was found on dissec- 
tion, the heart was not exactly of just proportions 
or of perfectly sound structure. We found this 
opinion partly upon the published accounts of 
those dissections, and partly on our own observa- 
tions both on the dead and living subject. It is 
easy to overlook slight misproportions in the dif- 
ferent cavities, and also various morbid conditions 
of the muscular fibre of the heart, which may 
have sufficed, nevertheless, to occasion the great- 
est distress or disorder in the action of the organ.- 
And in many cases of the milder forms of angina, 
we have been enabled to ascertain during life, by 
means of auscultation, that the heart was not ex- 
actly of healthy proportions, either in relation to 
its own parts individually, or to the system gen- 
erally. 

With the view of more fully corroborating the 
accuracy of these statements and opinions respect- 
ing the seat of pain in the paroxysm, we subjoin 
a brief outline of the results obtained on dissec- 
tion, in some of the principal cases recorded by 
authors since the time of Dr. Heberden. 

A. Results relative to the existence of organic disease in 

general. 

Total number of cases of which dissections are 
given -35 

Of this number there was no organic disease (ex- 
cept obesity) in 4 

Organic disease of the liver only, in -J 

Organic disease of the heart or great ves- 
sels, in 39 

B. Results relative to the nature of the organic affection* 

of the heart and great vessels. 

Total number of cases in which there was organic 
disease in the heart or vessels 3* 

Of this number there «as organic disease of the 
heart alone, in :o 

Organic disease of the aorta alone, in. . . > 

Organic disease of the coronary arteries 

alone, in 1 

Ossification or cartilaginous degeneration 

of the coronary arteries, in J(l 

Ossification or other disease of the valveF, 

in ;n 



108 



ANGINA PECTORIS. 



Disease of the aorta (ossification, or dila- 



tation, or both), in 24 

Preternatural softness of the heart,* 

in 13 

If wc consider it as proved, by the foregoing 
statements, that the heart and its great vessels 
constitute the seat of the pain and all the prin- 
cipal phenomena of the paroxysm of angina', it 
still remains to be inquired what is the nature of 
this pain, and what are its immediate causes, or 
the circumstances on which it immediately de- 
pends. And there seems no great difficulty in 
coming to a satisfactory conclusion in this matter, 
if we keep in view; 1. the facts recorded relative 
to the frequency of structural disease in the heart 
and aorta in angina; 2. the characters of the pain 
itself, its instantaneous invasion and cessation, its 
violence, its short duration, and its complete dis- 
appearance for long periods of time ; 3. the nature 
of the actions of the heart and great vessels in 
health ; and, lastly, the nature and causes of pain- 
ful affections in other parts of the body. 

We have no doubt that the pain, and other 
principal phenomena characterising the paroxysm 
of angina, may acknowledge different causes and 
depend on different conditions of the affected parts, 
in different individuals, and in the same individual 
at different times ; just as we find in other parts 
of the body, more particularly in parts possessing 
a structure and functions somewhat analogous to 
those of the heart ; namely, the hollow viscera 
possessing muscular tunics, and destined to con- 
vey fluids. The stomach, the intestines, the blad- 
der, the gall-ducts, ureters, &c, are all subject to 
sudden paroxysms of severe pain, frequently 
originating in very different causes, yet very simi- 
lar in their external character. In the stomach or 
bowels, for example, we may have gastralgia or 
enteralgia, of the same general appearance, from 
pure muscular spasm ; from matter irritating the 
internal membrane ; from simple neuralgia, the 
source of irritation being at the origin of the 
nerves; from over-distension, &c. &c. ; and each 
of these may exist with various organic diseases 
of the part, or without any organic disease ; and 
two or more of them may co-exist. It is reason- 
able to suppose that painful affections of this kind 
will much more easily be produced in a diseased 
organ than in a sound one ; and, indeed, experi- 
ence proves, that although almost all organs are 
liable to severe pains, from some unknown tem- 
porary condition of the nerves themselves, usually 
termed neuralgia ; yet that they are much more 
liable to such painful affections when diseased in 
their structure, and consequently disordered in 
their action or enfeebled in their powers. From 
what has been already stated of the fiequencv of 
structural disease of the heart and aorta neces- 
sarily disordering their action, it will readily be 
understood how easily pain may be induced in 
these parts under various circumstances, and from 
many different causes ; and it seems equally in- 
telligible how similar pains may originate in the 
same parts, under particular circumstances, even 
when no structural lesion exists in them. In 
this, as in so many other cases, authors have fre- 
quently failed in accounting for the phenomena, 
because they took too confined a view of the sub- 

* In a great many cases the consistence of the heart 
i* not noticed. 



ject, and were anxious to establish a greater sim- 
plicity in the production of the symptoms than 
nature acknowledges. 

Of the intimate nature of the pain in the pa- 
roxysm of angina we know nothing ; hut we know- 
no more of the nature of any pain. All that we 
can propound concerning it is a relation of the 
events which seem to lead to it, and the condition 
of the parts in which it occurs, at the time of its 
occurrence. We know that the pain is not of 
that kind which arises from inflammation, or ulce- 
ration, or any other fixed physical alteration of a 
part. All the circumstances attending it prove it 
to be of that kind which occurs in cramp or spasm, 
or from pressure, or in the class of cases termed 
neuralgic, in which the painful sensation is the 
result of some unknown temporary condition of 
the nerves of the part, not manifested by any 
physical alteration of them discoverable by our 
senses. We have sufficient evidence that such a 
morbid condition of the nerves may be produced 
in a heart in all other respects sound ; and when 
it takes place in a heart manifestly diseased in its 
structure, we must consider the structural lesions 
merely as predisposing and exciting causes of the 
pain. That the structural lesions are not the im 
mediate and necessary source of the pain is suf 
ficiently proved by its intermitting character, and 
the perfect ease in the intervals, when the struc- 
tural lesion is precisely the same as during the 
paroxysm. The anatomical structure, the pecu- 
liar action and functions of the heart and annex- 
ed great vessels, will sufficiently explain all the 
modifications of the pain and other phenomena 
observed in the anginous paroxysm. The radia- 
tion of the pain to a distance from the primary 
and principal site of it is only in conformity with 
what is observed in all other painful affections. 
Stone in the bladder produces pain in the glans 
penis ; calculus in the ureter, pain in the ab- 
dominal walls ; inflammation of the cartilages of 
the hip-joint, pain in the knee ; and what is per- 
haps a still more appropriate illustration, irritation 
at the origin of nerves in general frequently mani- 
fests itself only by pain at their extremities. In 
a word, the pain, in the paroxysm of angina, may 
arise from neuralgia, from spasm, from over-dis- 
tension ; and the other principal phenomena, may 
all, we think, be explained by the derangements 
of the functions of the heart, considered as a 
muscular organ charged with the office of circu- 
lating the mass of blood. 

Varieties of Angina. — Under this head we 
do not mean to notice the different forms of the 
paroxysm as witnessed in different cases. Such 
distinctions are of little practical value. We wish 
here to advert to the different circumstances, whe- 
ther of a local or general kind, under which the 
paroxysms take place, and which may materially 
influence both the prognosis and the treatment. 
Some of the most remarkable of these differences 
have reference to the. physical condition of tht 
parts immediately affected in the paroxysm ; others 
to the state of the general system with which the 
local affection is connected. We shall briefly 
notice the chief of these varieties in the ordei 
now stated. 

In one class of cases there exists great structu- 
ral disease of the heart and aorta : in another 



ANGINA PECTORIS. 



109 



class there exists either no structural disease, or 
none that can be detected. The former class of 
cases may therefore be termed organic angina ; 
the latter, functional angina. Each of these classes 
may be subdivided according as the affection of 
the heart and aorta exists uncomplicated with 
other diseases of a general or local kind, or co- 
exists with some such disease or diseases on which 
it is more or less dependent. This classification 
would give the following arrangement : — 
I. Organic angina. 

1. Pure, or idiopathic. 

2. Complex, or sympathetic. 
II. Functional ungina. 

1. Pure, or idiopathic. 

2. Complex, or sympathetic. 

1. The cases that come under the first subdivi- 
sion of organic angina are few in number. They 
are those in which the anginous paroxysms seem 
to be the direct consequence of organic disease of 
the heart occurring in persons otherwise healthy. 
Cases of this kind are seldom very well marked, 
the anginous symptoms being either feebly mani- 
fested, or overpowered by the greater intensity of 
the more ordinary symptoms of heart disease. 
These may be considered, in one respect, as the 
worst cases of angina, inasmuch as they hold out 
little prospect of cure or even of alleviation. Our 
influence over diseases of the heart is very slight, 
except they are partly the effect of some other 
disorder of a more curable kind. 

2. Under the next subdivision of organic angi- 
na, we would include the greater number of the 
best marked and more severe cases of this disease. 
In these, along with the organic affection of the 
heart or vessels, or both, (probably not very great, 
or, at least, marked rather by the paroxysm of an- 
gina than by the general symptoms of diseased 
heart,) we have some obvious general disorder of 
the system. In cases of this kind, the organic 
disease of the heart and aorta seems often to be a 
consequence of the co-existing disorder ; if not a 
consequence, it is always greatly aggravated by 
its presence ; and hence the most successful medi- 
cal treatment of the angina is that which has 
direct reference to the concomitant disorder. 

Among the various structural affections former- 
ly detailed as constituting the essential or organic 
character of these two classes of cases, different 
authors, at different times, have been anxious to 
select some one lesion as the exclusive cause of 
the disease. The principal of these have been, — 
ossification of the coronary arteries, ossification 
and dilatation of the aorta, accumulation of fat in 
or around the heart, &c. To these may be add- 
ed, with equal propriety, several other morbid 
states of the heart, particularly — softening of the 
muscular substance of the heart, dilatation of one 
or more of the cavities, &c. It will be at once 
admitted as a necessary consequence of the result 
of the, dissections given above, that no one of 
these lesions is entitled to be considered as exclu- 
sively the cause of the paroxysm of angina ; and 
that some of those which have been most gener- 
ally believed to be such, are equalled or exceeded 
in point of frequency by others. Thus we see 
that the ossification of the coronary arteries, for- 
merly considered by so many as the chief or sole 
cause of the paroxysm, is only of the same fre- 



quency of occurrence as disease of the valves, 
while disease of the aorta is much more frequent 
than either. But we think it probable that much 
slighter deviations from the normal condition of 
the organs of circulation than any above noticed 
constitute quite as frequent causes of this disease ; 
more particularly of the milder cases. In a cer- 
tain proportion of this class of cases it is not 
always possible to detect, during life, the exist- 
ence of any organic lesion, much less the precise 
lesion ; and from the same cause, (its slightness,) 
it is frequently overlooked in the examination after 
death. In a considerable number of such cases, 
however, the nature of the morbid deviation is 
discoverable both during life and after death. The 
most common of these slighter deviations from 
healthy structure are, a thin and slightly dilated 
state of the ventricles, and a want of tojie in the 
muscular fibre. 

3. We consider cases of the kind just mention- 
ed, in which the organic deviation is so slight as 
to be hardly discoverable, as constituting the great- 
er number of those usually viewed by practitioners 
as examples of pure functional or nervous angina. 
It is obvious that in extreme strictness of lan- 
guage they are not entitled to this name ; yet if 
the deviation is only so slight as to constitute mere 
feebleness, (and it is often nothing more,) they 
are probably as well entitled to the name as most 
other diseases commonly denominated nervous. 
But it must be admitted that in persons possessing 
the best- proportioned hearts, and in which no de- 
viation whatever from the normal structure can 
be detected either during life or after death, there 
may and do occur paroxysms of angina. The 
proportion of such cases is however very small 
under any circumstances in a state of uncompli- 
cation with other diseases ; and we look upon 
them rather as of possible occurrence than as hav- 
ing certainly met with them in practice. Con- 
joined, however, with some other disorder, as in 
the next class of cases, we conceive they are by 
no means rare. 

4. Under the head of complex or sympathetic 
functional angina, we must comprehend a large 
class of cases ; and, for the reasons stated in the 
last paragraph, although not strictly philosophical, 
we would, for practical purposes, include under 
the present division all the cases of nervous angi- 
na complicated with other diseases, whether the 
organs of the circulation are perfectly sound and 
well proportioned, or only deviating in a very 
slight degree from this state of integrity. Under 
this head are comprehended a very considerable 
proportion of the cases met with in practice, and 
not a few of those which present symptoms of the 
greatest severity in the paroxysm. 

The limits of this article prevent us from enter- 
ing into any lengthened details respecting the 
morbid states, general or local, which complicate 
angina, whether as simple coincidents or as piedis 
posing causes. It is highly necessary, however, 
that the attention of the practitioner should be 
particularly called to them, since, as has been al- 
ready observed, almost all our remedial measure.-, 
must be directed rather against these complication!.! 
than against the local affection which gives the 
disease its name and character. 

Of these complications, there is none more 



no 



ANGINA PECTORIS. 



desentng of notice than that multiform affection 
which is most commonly known by the name of 
dyspepsia. In its earliest and simplest stage, 
when consisting chiefly of mere functional disor- 
der of the stomach, this affection is a frequent 
concomitant of angina, and sometimes is the ex- 
citing cause of the paroxysms. In nervous habits 
it gives rise to much general disturbance, and ag- 
gravates local diseases, both by inducing general 
debility and exciting particular sympathies. It is, 
however, in its latter and more complex stages, 
that dyspepsia displays its principal power in 
modifying the condition of the system ; and it is 
in these that its connexion with angina is most 
conspicuous. In place of mere functional disor- 
der of one organ, there are now fixed structural 
changes in many ; while numerous new functional 
disturbances are added to the primary one, and all 
5re become fixed by long habit. The mass of 
blood itself, and most of the secretions and excre- 
tions have likewise become changed both in quan- 
tity and quality. 

This general disorder of the system, which may 
be termed secondary dyspepsia, sometimes gives 
rise to symptoms of angina, without any previous 
organic affection of the heart or aorta. It fre- 
quently also produces organic affections in these 
parts ; and if these already exist, it is one of the 
most common and most powerful exciting causes 
of the anginous attacks. When, co-existing with 
angina, this general disorder, in its progress, gives 
occasion to other local diseases of a fixed charac- 
ter, the consequence is sometimes an alleviation 
of the anginous symptoms, sometims an aggrava- 
tion of them. The organs which principally suf- 
fer in this way are the brain, the liver, the uterus, 
and the skin. When the irritation has fixed itself 
in the brain, the case becomes more distressing 
and unmanageable ; as then, in addition to the 
various bodily disorders, we have to combat the 
frettulncss and fickleness of a depraved temper, 
and all the mental miseries of hypochondriasis. 

There is no mistake more prevalent in this 
country, or more practically injurious, than that 
inflammation or other organic lesions of the liver 
are of frequent occurrence as primary diseases ; 
much more, that they are among the causes which 
exert the most powerful influence in modifying 
conditions of the whole system, and in excitinsr, 
by their sympathetic relations, numerous other 
maladies. Functional disorder of the liver is, no 
doubt, a very common effect of secondary dyspep- 
sia ; and when this has subsisted a long time, 
structural lesion, under the form of chronic inflam- 
nation, or induration, or hypertrophy of the gland, 
may be the consequence. But we are well assured 
that disease of the liver is rare in this country as 
a primary affection ; and we believe that when it 
exists, it exerts less influence over the rest of the 
iconomy than is commonly believed. 

When, from any cause, hypertrophy of the 
liver has arisen, the viscus may encroach, more 
or less, upon the natural boundaries of the chest, 
and impede or derange the healthy movements of 
jts contents. And it is from having seen some 
cases of this kind, and from having overlooked 
the more powerful agency of the accompanying 
disorders, that Breru, Portal, Latham, and others, 
hive considered angina as a mere sympathetic 



affection of the heart produced by the encroach- 
ments of the liver, or other abdominal viscera, on 
the boundaries of the chest. Nothing can be 
more incorrect than this view of the case, aa ap- 
plied to angina generally. It is open to tin 
of overlooking numerous and obvious causes of a 
much more influential kind, and selecting one thai 
is at once insignificant and of rare occurrence. 

The affections of the uterus seldom extend be- 
yond the mucous membrane ; but as irritations 
of this organ are important, both as creating local 
drains, and as producing, by extensive sympathy, 
irritation and disorder in the nervous system ; and 
as they, moreover, very generally induce some de- 
rangement of the important function of menstru- 
ation ; they deserve great attention from the prac- 
titioner when they complicate angina. 

One of the most constant and important com- 
plications of angina is that state to which we com- 
monly give the name of plethora, and which is 
supposed to consist essentially in an overloaded 
condition of the vascular system, in other words, 
a superabundance of blood. It is probable, how- 
ever, that in the great majority of cases, the blood 
is altered in its quality no less than in its quan- 
tity, the most common alteration being an increase 
of its nutritive properties. This, at least, is the 
most usual condition of it observed in angina. 
Independently of actual proofs of the existence 
of such a state furnished by the symptoms, almost 
everything in the history of angina countenances 
such an opinion. 1. The subjects of angina are 
mostly of the male sex, above fifty years of age, 
and a great majority of them belong to that class 
of persons who are enabled to indulge in full liv- 
ing, without the necessity of undergoing severe 
bodily labour, or even of using active exertion. 

2. Gout is a very frequent disease in persons sub- 
ject to angina ; and gout scarcely ever occurs 
fexcept in extreme cases of hereditary predisposi- 
tion) in persons that are not of a plethoric habit 

3. Obesity is extremely common in angina. The 
deposition of fat in the internal parts is. indeed, 
so common, that many writers are disposed to 
consider the fatty accumulation as the cause of 
the paroxysms. 4. The very existence of angina, 
from whatever cause arising, tends to produce ple- 
thora if it did not previously exist, or to increase 
it if already present. A sedentary life, and the 
abandonment of all active bodily exertions, are 
almost inevitable consequences of this disease; 
and if the appetite continues good, as it often docs, 
and if no dietetic regimen, having reference to 
the diminished wants of the system, is enforced, 
the occurrence of plethora can hardly be avoided. 
5. We consider the formation of osseous deposits 
in the aorta, coronary arteries, &c, so prevalent 
in angina, as an indication at once of plethora and 
of that concomitant depravation of the blood 
wdiich we know generally to precede the deposi- 
tion of analogous morbid substances in gout, cal- 
culus, &c. 6. The beneficial effect of various 
kinds of medical depletion and low living, and the 
ill effects of opposite practices, strongly corrobo- 
rate the same view of the case. 

The connexion of angina with the gouty habit 
deserves some further notice, as being a matter of 
great importance in respect both of the pathology 
and treatment. This connexion was early ob- 



ANGINA PECTORIS. 



Ill 



served, and has had considerable influence in 
mollifying the opinions and practice of many 
writers on the subject of the present article. But- 
ter seems to have been the first who particularly 
noticed it. He, indeed, considered angina as no- 
thing more than a form of gout. Similar opinions 
are entertained by many subsequent writers, as by 
Macqueen, Eisner, Stoeller, &c. ; and when stated 
with due regard to philosophical accuracy of lan- 
guage, there can be little doubt that this opinion 
is correct in a very considerable number of the 
cases of angina. The fact is, that in such cases 
there exists the same general disorder of the sys- 
tem as in gout, of which one of the most obvious 
features is the state of plethora above mentioned. 
In a certain proportion of these cases we have all 
the local characteristic phenomena of gout, either 
co-existing or alternating with angina ; in others 
we have the same constitutional symptoms, but 
the local disorder of the heart and great vessels in 
place of that of the joints. No doubt, there exists 
some real difference between the two classes of 
cases, which gives to one the characteristic form 
of angina, and to the other that of gouty inflam- 
mation of the extremities 5 but the nature of this 
difference altogether eludes our observation in 
most instances. It is sufficient for our present 
purpose to be aware of the fact that, in a certain 
proportion of the cases of angina, the same appa- 
rent constitutional disorder exists as in gout. This 
fact is abundantly proved by the evidence afforded 
by the published cases of angina, and is corrobo- 
rated by all that we have ourselves observed of 
this disease. 

Treatment of Angina* — Like that of all dis- 
eases of an intermitting or paroxysmal character, 
the treatment of angina requires to be considered 
in two very distinct points of view, — in the pa- 
roxysm, and in the interval. We shall therefore 
notice these separately. 

I. Treatment in the paroxysm. — As there can 
be no doubt that the paroxysms of angina arise 
under very different conditions of the system, and 
as they differ very materially in their immediate 
causes, or in the condition of the organs immedi- 
ately affected, all rational treatment must have re- 
gard to these circumstances in individual cases, as 
far as they are known or can be ascertained. 
Painful muscular spasm, or simple neuralgia of 
the heart and aorta, whether ultimately depend- 
ing on organic disease of the parts or not, may 
recognise very opposite exciting causes, and may, 
therefore, be best relieved by different means. 
In one case, for instance, the patient may be 
strong and robust, and his whole vascular system 
overloaded ; in another, he may be the victim of 
long previous disease, with a deficiency both of 
blood and constitutional power ; while, in a third, 
the system may be comparatively healthy, with or 
without local disease of the organs of circulation, 
and with or without great nervousness of tempe- 
rament. In all these varieties, the treatment will 
require modification to suit it to the individual 
case. When previously known, such circum- 
stances must, therefore, be kept in mind by the 
practitioner \ when not known, an attempt must 
be made to ascertain them before he prescribes for 
the patient. Inattention to circumstances of this 
kind has often rendered the treatment much less 



effective than it might have been, or has rendered 
it decidedly injurious. It must be confessed, how- 
ever, that in many cases it is extremely difficult, 
if not impossible, to come to any certain judgment 
as to the actual pathological condition of the 
affected parts, or even of the system generally, 
during the paroxysm. A previous knowledge of 
the patient, and, yet more, the having had oppor- 
tunities of studying the case in former attacks, 
will here be of the greatest importance. 

The violence of the patient's sufferings, and the 
belief in the nervous or spasmodic nature of the 
pain, suggested by its sudden invasion, would na- 
turally lead the medical attendant, in the first 
place, to attempt to afford relief by anodynes. 
And such, we find, has been the common prac- 
tice of physicians when first called to a patient in 
a paroxysm, or when requested to prescribe means 
with the view of checking or mitigating its vio- 
lence in case of recurrence. Such attempts, how- 
ever, have generally been attended with less suc- 
cess than might have been expected. Rarely, in- 
deed, if ever, has a paroxysm been speedily and 
completely removed, by such means ; and only 
in a very small proportion of cases has its violence 
been mitigated. In angina, as in tooth-ach or 
tic douloureux, gastralgia, colic, or other violent 
pains, nature seems as if she scorned to be con- 
trolled by art, although so much under the influ- 
ence of similar applications when less needed, as 
in the case of milder pains. And, no doubt, in 
the disease now under consideration, the state of 
mental distress and fear with which the bodily suf- 
ferings are complicated, has a powerful influence 
in counteracting the ordinary effect of anodyne 
remedies. Our own experience would lead us to 
recommend the use of anodynes in the milder- 
cases only ; and more particularly in those in 
which there existed a feeble and exhausted sys- 
tem, or great constitutional nervousness without 
plethora. 

Antispasmodics, cordials, carminatives, &c, 
have been also much recommended and employed; 
and, upon the whole, with better success than 
anodynes. They have appeared, in different 
cases, to afford relief by imparting a temporary- 
vigour to the nervous system generally, overpow- 
ered as it seemed by the bodily and mental suf- 
ferings ; or by stimulating the heart to increased 
action, and thereby enabling it to propel the load 
with which it was oppressed ; or, simply, by in- 
vigorating the stomach, and enabling it to expel 
the flatus accumulated in it. And it seems pro- 
bable that such means may operate in all these 
ways, and, perhaps, conjointly in the same ease. 
In cases in which there exists sufficient evidence 
of a plethoric state of the vascular system, some 
attempt must be made to remove this before means 
of the kind now under consideration can be ap- 
plied with any prospect of benefit, or even safety. 
In most cases where venesection has been em 
ployed, and particularly if it has been carried to a 
considerable extent, slight doses of laudanum, 
combined with brandy or other stimulants, may 
be used, always with safety, and often with be- 
nefit ; and the probability of benefit will be greater, 
in proportion to the degree of exhaustion and 
nervousness present. The aromatic and stimulant 
medicines, usually termed carminatives, are inn- .5 



112 



ANGINA PECTORIS. 



particularly indicated in dyspeptic complications, 
and where there exist signs of distension of the 
stomach by flatus. 

This circumstance of the stomach being so ge- 
nerally oppressed with flatus during paroxysms 
of angina, and of the expulsion of this being al- 
most always the harbinger of relief, if not its 
cause, is a remarkable feature in the history of 
the disease. In reading the numerous cases re- 
corded, one is struck with the frequent mention 
of this circumstance; and our own experience 
entirely corroborates the observations made by 
others, that it is by no means rare in subjects 
who are altogether free from any signs of indi- 
gestion in the intervals of the paroxysms. From 
this and other considerations, there seems little 
reason to doubt that the gas is formed in the in- 
testinal canal during, or immediately before, the 
paroxysms. Be this as it may, there can be no 
doubt that its expulsion during these, forms, in 
most cases at least, a rational indication of treat- 
ment ; since, whether a cause or consequence of 
the paroxysm, its expulsion almost invariably 
gives relief:* and it is sometimes found that the 
simple aromatic waters are more effectual in pro- 
ducing this result, than medicines usually consi- 
dered of greater power.j- 

A very different mode of relief, already noticed, 
namely, venesection, has been occasionally em- 
ployed with much advantage ; and there is great 
reason for believing, that, if more judiciously ap- 
plied, it would have been still more beneficial. 
Several different circumstances met with in pa- 
roxysms of angina, sometimes separately, some- 
times conjointly, seem fully to justify the trial of 
this remedy, even if its use had not been vindi- 
cated by experience. These are, the state of ge- 
neral plethora, so frequently found in such pa- 
tients ; the state of actual local plethora or morbid 
accumulation of blood in the heart and large ves- 
sels ; the state of relative local plethora of the 
same parts from feebleness of the organ in pro- 
pelling its contents. In all these cases the dimi- 
nution of the mass of blood, if it can be effected 
without immediate risk of life, would unquestion- 
ably be beneficial ; and the practice of several 
eminent men has proved it to be often safe. Dr. 
Percival, Dr. Parry, Dr. Hosack, Mr. Allan Burns, 
and several others, are of this number. We have 
ourselves employed it with benefit in some strongly 
marked cases of angina ; and the instantaneous 
and signal relief which every physician must have 
otten observed from venesection in organic dis- 
eases of the heart, leaves no doubt of its useful- 
ness in this disease, when employed with discri- 
mination, and with the necessary precautions. 
These precautions are well stated by Dr. Parry in 
his Inquiry, in the following terms : " The patient 
should be placed in the horizontal posture, and 

* The apparent influence of pas in the stomach over 
the motions of the heart is very remarkable. In certain 
nervous diseases, we have seen intermissions of the 
heart's action carried to such an extent that the patient's 
life was considered in imminent danger ; and yet have 
known the whole symptoms instantly removed hv the 
sudden expulsion from the stomach of a quantity of 
flatus! 

- In a case related hy Dr. Fothergill, simple pepper- 
mint water is said to have given great relief in this 
way : " It was always hy him in the night, and pave him 
ease when a reasonable dose of paregoric had been given 
without benefit." Fother^ill's Works, ii. 253. 



blood should be taken away from a very small 
orifice, while, at the same time, the finger of the 
physician is applied to the pulse, in order to de- 
cide on the propriety of continuing or discon- 
tinuing the flow of blood. If no person of ade- 
quate judgment is at hand, it may be right to re- 
strict the quantity of blood taken away to about 
three ounces at any one operation." (On Syn- 
cope Anginosa, p. 164.) We have already 
stated, that where this measure is deemed ad- 
visable, it ought to take precedence of the ad- 
ministration of cordials, which are much more 
likely to act beneficially after the heart has been 
partially freed from the load which was oppress- 
ing it : and such remedies will, in most cases, be 
very properly administered after detraction of 
bloody 

As the affusion of cold water in the paroxysm 
of angina has been mentioned as a remedy by 
some authors, we notice it here chiefly with the 
view of entering a caution against its employment. 
It can rarely be employed with benefit or even 
safety. The partial application of cold water, 
however, may be sometimes admissible as a stimu- 
lant of the nervous system, just as we apply it in 
hysteria. A curious case of severe angina is re- 
lated by Joseph Frank, in which the patient, a 
medical man, found singular relief from the appli- 
cation of cold water to the head ; and the relief 
was more speedy, if, during the application of the 
water, the left hand was placed, in a particular 
manner, on the head. The same author relates a 
case in which the impending paroxysms seem to 
have been averted by the cold affusion ; but, as 
already stated, we cannot consider such a practice 
as generally safe.§ 

[Laennec affirmed, that the remedy which most 
frequently succeeded with him in procuring alle- 
viation, in cases of angina pectoris, and of neuralgia 
of the heart of a slighter kind, and without radiating 
pain, was the magnet ; which he employed in the 
following manner : two steel plates, strongly mag- 
netized, of an oval form, and slightly arched, so as 
to admit of close application to the parietes of the 
thorax, were placed, — the one on the left pericar- 
dial region, — the other on the opposite part of the 
back, in such a manner that the poles may be 
exactly opposite, and the magnetic current may 
traverse the part affected. When it procured but 
little relief, a small blister was applied under the 
anterior plate with advantage. Dr. Hope {Trea- 
tise on Diseases of the Heart, Amer. edit., by Dr. 
Pennock, p. 466 : Philad., 1842,) states, however, 
that they who witnessed the application of the 
magnet by Laennec, did not, in general, form so 
favourable an opinion of its utility as he did. It 
appeared to be more successful when combined 
with acupuncture. Its effects are doubtless alto- 
gether revellent.J 

But although these or other means may occa- 
sionally afford relief, or may even ward off death, 
it is evident that every kind of treatment confined 
to the paroxysm is of very slight importance, when 

X A stronply marked instance of the good effects of 
venesection in the paroxysm of angina is given hv Dr 
Head, m the Dublin Trans. Vol. i. 105; and a pood llusi 

tration of the injurious effects of prematurely stimulat- 

ng a feeble heart already oppressed with itecontents 

is recorded in Parry's work, p. ](',:!. ulen, *> 

§ Prax. Med. Univ. Part ii., vol sii. n. 273 274 nota 



ANGINA PECTORIS. 



113 



compared with that which is to be employed in 
the interval : the former can, at most, afford tem- 
porary relief; the latter may cure the disease. It 
is to this part of the treatment, therefore, that the 
care of the practitioner is to be chiefly directed ; 
and it is to this part of our subject that we would 
claim his especial attention. 

II. Treatment in the interval. — If it is of con- 
sequence for the practitioner to be acquainted with 
the precise nature of the case before him, to ena- 
ble him to prescribe successfully or even safely in 
the paroxysm of angina, it is much more impor- 
tant that he should have this knowledge to direct 
his treatment in the interval. In many cases, no 
doubt, it is quite impossible to ascertain the inti- 
mate character of the affection during the parox- 
ysm ; and in a certain proportion of these, the 
knowledge, if attainable, would be of little use. 
We should still be reduced to the necessity of ap- 
plying the same limited stock of means without 
any very inspiring confidence of a beneficial result. 
Circumstances, however, are very different in the 
interval. Here, an accurate acquaintance with the 
nature of the individual case is indispensably ne- 
cessary to enable us to institute treatment that 
holds out any prospect of success ; while a prac- 
tice adopted at hazard, or on merely empiricial 
principles, may not only be useless, but may lead 
to the most disastrous results. The first and great 
object of the practitioner, therefore, on being called 
on to treat a case of angina, will be to make 
himself acquainted with its individual character. 
Beginning with the early history of the disease, 
he will trace it to its present stage, and will endea- 
vour, from the narrative of the patient, and from 
the observation of the whole phenomena presented 
to him, to form a clear judgment respecting the 
local condition of the organs in which the charac- 
teristic symptoms have their site ; and the state of 
all the other parts of the system, which can in any 
way influence these : in other words, he must en- 
deavour to ascertain the species or variety of angi- 
na, according to the distinctions formerly pointed 
out. Are the paroxysms dependent on some 
structural lesion of the heart and great vessels, or 
are these organs in their original soundness ? If 
there is any deviation from the sound condition of 
these organs, what is the nature of this deviation ? 
Does structural lesion exist or not ? or, if existing, 
can it be detected or not ? What is the actual 
physical condition of the heart ? Are its walls 
thick or thin ? Are its cavities large or small ? 
What is the state of the general health ? Is it 
such as injuriously to influence the recurrence of 
the paroxysms in any way, or to aggravate their 
severity } If thus injuriously influencing the local 
disease of the heart and great vessels, is it of a 
kind to be remedied or mitigated by medical treat- 
ment ? These queries comprehend most of the 
subjects of inquiry which the practitioner who 
proceeds to treat a case of angina, must keep in 
view ; and although it will sometimes be impossi- 
ble to obtain precise information on every point, 
yet this will be practicable, in the greater number 
of cases, by care and attention, and by the employ- 
ment of the improved methods of investigating 
thoracic diseases furnished by auscultation. This 
latter method of exploration will, in a more par- 
ticular manner, aid our recognition of the physical 
Vol. I.— 15 x* 



condition of the heart ; and enable us, in a great 
number of cases, to determine the presence or ab- 
sence of organic disease in that organ. This pre- 
cise knowledge is, no doubt, important in assisting 
us to regulate our practice with the best advantage 
to the patient ; but it is infinitely more so in ena- 
bling us to form an accurate prognosis respecting 
the event of the case. If the attacks recognise 
great structural lesion of the heart or aorta for 
their cause, we can only expect to mitigate the 
severity of the paroxysms, or to effect their tempo- 
rary removal. If there exists no structural lesion 
of a fatal kind, although the organs may not be of 
the soundest proportions, it is often practicable, 
not merely to mitigate or remove the paroxysms, 
but by great and constant vigilance on the part of 
the patient in avoiding the exciting causes, to pre- 
vent their recurrence altogether. When the dis- 
ease is purely one of functional disorder, a much 
more perfect and permanent cure may be expected. 
In all these cases, however, the general character 
of the treatment will not greatly vary. An or- 
ganic lesion of the heart, even of an incurable 
kind, can only be viewed, in relation to the treat- 
ment, as a predisposing cause of the attacks, just 
as a heart that is naturally feeble or morbidly irri- 
table is so ; and it is only in rare cases that the 
organic lesion induces the paroxysm without the 
aid of obvious exciting causes. No doubt, exciting 
causes of a much feebler kind will suffice ; but 
the very necessity of such causes at all to produce 
the effect, brings the case, as far as concerns the 
prevention of the paroxysms, under the same cate- 
gory as to treatment as the purely sympathetic or 
nervous angina. In the case of organic disease, 
however, our expectations of benefit from treat- 
ment, and the actual results, become wonderfully 
less. Now, indeed, we fight not for victory, but 
merely to keep the enemy at bay. We, however, 
use the same weapons ; and if we do not strive 
with the same enthusiasm, we must, at least, be 
vigilant and active; and- we shall often be re- 
warded with a degree of success that we scarcely 
dared to hope for at the commencement of our 
treatment. For these reasons, in the following 
outline of what we conceive to be the proper 
treatment of angina, we shall, for the most part, 
treat of the disease generally, and refer only to its 
individual forms when this becomes essential from 
the necessity of recommending some peculiarity 
of treatment. 

In the small number of cases in which the an- 
ginous paroxysm depends upon organic disease of 
the heart, uncomplicated with other disorders of 
the system of a general or local kind, our mode 
of treatment becomes very simple. It consists, in 
a great measure, in guarding against the causes 
which obviously excite the attacks, and in observ- 
ing a most cautious and rigid regimen. These 
measures will be more particularly noticed pre- 
sently, and they will be still more fully discussed 
in the articles which treat of certain other diseases 
of the heart. The remedies of a more direct and 
specific kind, which may influence the recurrence 
of the paroxysms, will also come under our notice, 
after we have considered the treatment best calcu- 
lated to reduce the more common and complex 
cases of angina to the stale of simplicity now 
under consideration. The same remark will appl" 



114 



ANGINA PECTORIS. 



to the cases of angina of the more purely nervous 
kind, and also to those which are connected with 
mere organic feebleness of the heart. Tin 1 gnat 
rarity of such cases, compared with the frequency 
of those of a more complex kind, renders the 
treatment of them of comparatively little conse- 
quence. And there is an additional reason for not 
entering upon the consideration of the treatment 
of such cases at present, namely, an apprehension 
lest the attention of the inexperienced reader 
might, in the outset, be too strongly arrested by 
the specific remedies applicable to them, and be 
thus diverted from the very different kind of ma- 
nagement requisite in the more complex class of 
cases, which, unquestionably, constitute the vast 
majority of those met with in practice. 

We must refer to other parts of this work for a 
detailed account of the treatment of the various 
disorders formerly noticed as complicating angina, 
or as constituting what may be termed its consti- 
tutional form. The presence of the anginous pa- 
roxysm renders scarcely any modification in the 
treatment necessary. On the present occasion we 
can only make a few general remarks on some of 
the most important of these complications. 

Of the treatment of simple or primary dyspep- 
sia, as co-existing with angina, we shall only here 
remark, that much more is to be effected by a ra- 
tional system of diet and regimen, both of body 
and mind, than by medicines ; and that, as a 
general rule, the cautious, cooling, and macerating 
treatment of our continental neighbours, will be 
found more successful than the endless ingestion 
of bitters and drastic purges, so much practised in 
this country. In many cases, no doubt, the sto- 
mach is simply debilitated, and requires tonics ; 
but it is much more frequently irritated or inflamed, 
and requires soothing and depiction. The prevail- 
ing and most injurious error among many practition- 
ers, is, apparently, to overlook the fact, that the 
stomach or intestinal canal can be inflamed without 
pain or the more common external marks of febrile 
action ; or, being so, that they can be injured by the 
stimulus of purging. But it is in the complex 
constitutional disorder, vvfncK may be termed 
secondary dyspepsia, that these observations are 
most applicable. It is to be feared that the true 
nature of this disorder is not well understood by 
the generality of practitioners. It is one of those 
diseases which may often be said to be the oppro- 
bria medicorum in the worst possible sense ; since 
it is not seldom caused, and is very frequently 
fixed and perpetuated by injudicious treatment. 
In no other disease is the over-active, or, as our 
neighbours term it, heroic mode of practice so pre- 
valent in England, productive of such evil effects; 
and in none is that mild, simple, yet comprehen- 
sive system of treatment, which embraces the 
whole of the disordered organs and functions, and 
rather prompts nature to act rightly than super- 
sedes her agency, so strikingly beneficial. (See 

DrSFEPSIA.) 

In the very numerous class of cases in which a 
alethoric state of the system co-exists with angina, 
ana in many of which there is either actual gout 
01 the gouty diathesis, the chief indications will 
be, first, to relieve the overloaded vessels; and, 
secondly, to prevent their repletion. Here the 
most obvious and immediate remedy is venesec- 



tion. This may, in most cases, be beneficially 
employed as a means of temporary relief, and will 
advantageously be combined with the use of pur- 
gatives, colchicum, &c; but the cure of the dis- 
ease, if it is curable, or its effectual relief, must 
depend on measures of more permanent operation. 
These are much more dietetical than medicinal. 
In the kind of cases now under consideration, and, 
indeed, in the great majority of all the cases of 
angina, a most strict regimen, and as low a diet as 
is consistent with the maintenance of healthy 
function, is absolutely necessary. It is not to be 
inferred from this, that the complete abandonment 
of animal food by the patient is recommended. 
This probably may be necessary partially, or for a 
time, but not generally. All that is essential to 
be kept in view is that the diet be of such a kind 
as not to be too nutritive, or to occasion fulness. 
In many persons, more particularly of the class 
whose cases we are now considering, an exclu- 
sively vegetable diet will prove injurious, by pro- 
ducing disorder of the stomach. And it is always 
to be kept in mind, in treating such cases, that it 
is almost of as much consequence to avoid local 
morbid irritation of this organ as to obviate ple- 
thora. We think, however, that a case can hardly 
occur in which it will not be proper to limit the 
patient to the milder kinds of animal food, and to 
a very moderate proportion of this ; the great bulk 
of the nutriment being farinaceous. In certain 
cases, a small portion of wine may be allowed j 
but it will scarcely ever be proper to permit it to 
be taken in considerable quantity; and malt liquor 
must be at once and for ever abandoned, in all 
forms and proportions. In certain of the moie 
violent forms of organic angina, it may sometimes 
be advisable to attempt the relief of the disease by 
a systematic reduction of nutriment below the 
actual wants of the system, as practised by Val- 
salva ; and we do not doubt that, if the selection 
of cases for the experiment were good-, and phy- 
sicians and patients could be found endowed with 
sufficient faith and courage to enforce and undergo 
the trial, the very best results might occasionally 
be obtained. But it must be confessed that such 
a mode of practice is but ill suited both to the 
weakness of humanity and the uncertainty of the 
healing art. 

It is in the class of cases now under considera- 
tion that counter-irritants are most indicated; more 
particularly if the plethora is complicated with the 
predisposition to gout, or with actual gout. And, 
certainly, of all the various remedies that have 
been used in angina, none seem to have been, on 
the whole, attended with more success than this 
class of agents. As a general rule, it may be 
observed that counter-irritation is much more 
beneficial in those diseases in which there existed, 
previously to the local affection, a well-marked 
disorder of the system at large, than in cases of 
pure inflammation produced by accidental causes 
in a system otherwise healthy. In the former case, 
the artificial irritation and discharge frequently 
produce relief to the .system analogous in kind, 
however inferior in degree, to that which always 
attends the supervention of a spontaneous local 
inflammation in such cases ; while the institution 
of an artificial inflammation in the other class of 
cases, has frequently no other effect than that of 



ANGINA PECTORIS. 



115 



adding to the existing disorder and distress. Dr. 
Smyth, of Dublin, so far back as 1770, employed 
issues in several cases of angina with marked 
benefit, and, in two at least, with perfect success ; 
in a third case, the disease seems to have been 
removed by an issue of nature's own making, viz. 
by a hemorrhoidal discharge, first of blood, and 
then of pus. Dr. Macbride, who relates these 
cases, expressly states that one of these patients 
had a strong gouty taint. (Edin. Med. Coinm. 
vol. v. p. 12.) 

In Dr. Smyth's cases, the issues were applied 
to the thighs ; and the same practice was adopted 
by Darwin with equal success. " Four patients 
(says this author) I have now in my recollection, 
all of whom I believed to labour under angina 
pectoris in a great degree, which all have recovered, 
and have continued well three or four years, by 
the use, as I believe, of issues on the inside of each 
thigh ; which were at first large enough to contain 
two peas each, and afterwards but one. They 
took besides some slight antimonial medicine for 
a while, and were reduced to half the quantity or 
strength of their usual potation of fermented 
liquor." (Zoonomia, vol. iv. p. 43.) The reader 
will understand the importance of the restriction 
of the diet mentioned in this case. 

Irritants applied directly on the cardiac region 
have been occasionally followed by no less fortu- 
nate results. In cases related by Goodwin, (Med. 
and Phys. Journ. vi. 320.) Kriegelstcin, (Hufe- 
land's Journ. B. xix. St. 4, p. 131.) Lind, (Med. 
Chir. Rev. N. S. iv. 497.) and others, a cure 
appears to have been effected by the application 
of antimonial irritants to the chest ; and, in Dr. 
Parr's case, great temporary relief followed the 
application of a blister to the same part. (Blackall 
on Dropsy, 365.) In a case noticed by Joseph 
Frank, great benefit, " conspicuum levamen," 
resulted from the insertion of an issue between the 
ribs in the cardiac region. (Med. Univ. Praecept. 
P. ii. vol. i. p. 269.) Two of Dr. Blackall's cases 
are very much in favour of this practice, although 
only offering analogical evidence of its efficacy. 
The subject of one of them, a gentleman who had 
never for a single week been free from attacks of 
angina for ten years together, lost every vestige 
of it for the last nine years of his life, during 
which he suffered from ulcers of the lower extre- 
mities. In another, a gouty subject, instantaneous 
relief during the paroxysm was more than once 
afforded by the application to the feet of " mustard 
cataplasms, quickened with oil of turpentine." 
(Loc. Cit. 409.) But it is not as isolated means, 
used empirically, that counter-irritants, or any 
other topical treatment, can be expected to pro- 
duce their full measure of benefit; it is only 
when had recourse to as parts of a comprehensive 
system of treatment, embracing the whole disease, 
that they can be used with much prospect of suc- 
cess, or, indeed, that they should be used at all. 
When their application is so regulated, both rea- 
son and experience counsel the measure in every 
case of obstinacy or great severity. 

A most important part of the treatment of an- 
gina is the avoidance of the exciting causes of the 
paroxysms. By rigid adherence to the proper 
regimen, and by constant vigilance on the part of 
the patient to eschew everything calculated imme- 



diately to induce a paroxysm, very much may be 
effected, even in the most hopeless cases, to alle- 
viate suffering, and in mere functional angina a 
cure may very generally be expected. In all cases 
the patient should be so far instructed in the 
nature of his complaint, as to be made aware that 
whatever tends to hurry the circulation beyond 
the medium standard, is likely to induce a parox- 
ysm, and he must have pointed out to him all the 
circumstances that are capable of producing this 
effect. He himself will, indeed, have learned, by 
sad experience, the chief of these circumstances, 
and will require no admonition to induce him to 
avoid them ; but there may be others, of the 
power of which he is not sufficiently aware, which 
may, nevertheless, be exerting a baneful influence 
over his malady. 

Some patients have been so bold as to endea- 
vour to master their paroxysms by persevering in 
the very acts which had induced them ;* and in 
some few cases the attempt has certainly been 
unattended with any bad effects, if it was not pro- 
ductive of good. These cases, however, were of 
the slighter kind ; and there cannot be a doubt 
that, in every case, all such attempts are to be 
forbidden. All strong exercises, and more par- 
ticularly walking up hill or up stairs, and, in a 
word, every species of bodily movement that is 
found to induce the paroxyms, must be abandoned 
as far as possible. Of this kind may be particu- 
larly noticed the act of stooping, as in tying the 
shoe-strings ; drawing on boots ; straining at 
stool ; climbing a high bed, &c. &c. Those posi- 
tions of the body which tend to lessen the cavity 
of the chest or abdomen, give double power to all 
contemporaneous movements that accelerate the 
circulation, and are therefore to be particularly 
avoided. It is chiefly on this account that a full 
meal greatly increases the bad effects of exercise ; 
although, in this case, no doubt, the fresh stimulus 
imparted to the circulation by the recent aliment 
co-operates. 

In regulating and limiting bodily exercise, how- 
ever, great care must be taken not to carry our 
precautions too far ; as insufficiency of muscular 
motion, by inducing morbid irritability of the ner- 
vous system, may operate almost as unfavourably 
as over-exertion. In all chronic nervous diseases, 
— and angina, even when depending on organic 
causes, must, in one respect, be considered as a 
nervous disease, — there is no species of treatment 
so beneficial as regular bodily exercise ; insomuch 
that, in the practice of medicine, we are almost 
justified in considering the nervous and muscular 
systems as antagonist powers : the more the one 
is exercised, the less irritable and excitable the 
other becomes. Accordingly, in sympathetic an- 
gina and the numerous analogous nervous affec- 
tions of the heart, we have invariably found the 
greatest benefit from a regular system of exercise, 
conjointly with other means calculated to restore) 

* A remarkable example of this occurred to the write* 

of the present article, while transcribing it for the press, 
in the person of a gigantic farmer, who seemed to fancy 
he ought to rule diseases as he ruled his team. When 
the paroxysms attacked him on horsehack, he would 
throw the reins on his horse's neck, put him to a canter, 
and bear his agony till he could sit no longerl When 
fairly beaten he came to the doctor, but it was too late 
hi' died suddenly during the night, not more than pighi 
davs after Ins first visit. 



116 



ANGINA PECTORIS, 



the different functions disordered. And even in 
the organic angina, sucli exorcise as can be borne 
must be strictly enjoined. If, from experience of 
the ill effects of his ordinary exercise, the patient 
has renounced all exercise, he must endeavour to 
renew the practice, beginning wilh the gentlest, 
both in kind and degree. By patiently persever- 
ing in this plan, he will often succeed in bringing 
the system to bear considerable exertions without 
augmenting cither the frequency or severity of the 
paroxysms. That kind of exercise which is borne 
best, will, of course, be most used ; but merely 
passive exercise will not produce all the effects we 
could desire. The muscles of locomotion must be 
kept in action. Riding on horseback, or walking, 
must therefore be enforced, as far as may be prac- 
ticable or justifiable ; and great care on the part 
of the patient, in avoiding all unnecessary trials 
of his powers, will often enable him to enjoy both 
these modes of exercise to a considerable extent. 
In walking, which is, on the whole, by much the 
best mode of exercise, the patient must strictly 
confine himself to level ground, and must not 
face the wind. For these reasons, the nature of 
the place of residence becomes frequently a matter 
of much consequence. If we are justified in send- 
ing other patients with chronic diseases from their 
homes, for the sake of a difference in the climate, 
we are warranted in doing the same, in the case of 
anginous patients, in order that they may obtain 
the advantage of a flat country, or sheltered walks. 
Change of air, indeed, in the usual sense of that 
phrase, is very beneficial in many cases of angina; 
but whenever this is recommended, the configu- 
ration of the surface of the new locality, and its 
degree of shelter from winds, must be considered 
as much as the nature of the climate. Occasion- 
ally we meet with instances in which hardly any 
degree or form of exercise can be borne ; the 
wretched sufferer being reduced, through the ever- 
present terror of a paroxysm, to a state of almost 
vegetable immobility. In such cases it will gene- 
rally be found that the only succcdaneum for the 
exercise that can no longer be taken, is a system 
of diet so rigid as to approach the limits of starva- 
tion ; and if the patient has sufficient courage to 
pursue this course, a greater relaxation from suf- 
fering may still be obtained than could have been 
anticipated. 

A most important chapter in the history of all 
diseases immediately connected with the functions 
of the heart, is that which treats of their relation 
to mental impressions ; and in no case is the con- 
sideration of this relation so important as in the 
prophylaxis of angina. Two varieties of mental 
affections act powerfully on the functions of the 
heart, — the depressing and the exciting passions. 
It may be difficult to prove that anxiety, care, 
grief, or any other form of mental distress, does 
ever of itself and directly produce disease of the 
heart ; because such states of mind, if continued, 
are followed by various other bodily disorders 
•vhich powerfully co-operate in deranging the 
functions, and eventually the structure of this 
organ. But no one who has lived in the bustle 
of life, and seen much practice, will doubt for a 
moment that the mental states now referred to are 
among the most prevalent and most influential of 
(he remote causes of such diseases. When angina 



already exists, it must be admitted that these, as 
well as the exciting passions, are among the most 
frequent exciting causes of the paroxysm. The 
result of the operation of both classes of emotion 
is the same, although somewhat differently brought 
about ; namely, an accumulation of blood in the 
heart disproportioned to its powers of propulsion. 
It is doubtful which of these causes is the most 
powerful. The exciting passions are usually con- 
sidered as such ; but it is probable that this opin- 
ion may have taken its rise from their more osten- 
tatious nature. Anger is a social and public pas- 
sion ; it is clamorous, and will be both seen and 
heard. Grief is retired, silent, and secret ; it is 
more conspicuous in its effects than in its work- 
ing. Anger is, no doubt, also quicker in its ope- 
ration than sorrow ; and the open and instanta- 
neous manifestation of its power in diseases of 
the heart has procured for it a greater reputation 
than has fallen to the lot of its less obtrusive but 
still more formidable sister. Very many examples 
of sudden death from anger, in diseases of the 
heart, are recorded ; and not a few of these have 
occurred in cases of angina. These statements 
prove the great importance of mental discipline in 
this disease ; and although « herein the patient 
must minister to himself," it is the duty of the 
physician to point out to him the necessity no 
less of the moral than of the physical means of 
prophylaxis. 

It will be remarked that, in the preceding ob- 
servations, we have taken no notice of specific 
remedies for the relief or cure of angina. The 
consideration of these has been purposely deferred 
until now, with the view of impressing upon the 
mind of the reader the much greater importance 
of those plans of treatment, which have reference 
to some obvious or intelligible disorder of the sys- 
tem. When no such disorder exists, or when, 
having existed, it has been removed, or, at least, 
has been afte/npted to be removed by every ra- 
tional means which medical science affords, then, 
and not till then, are we justified in making trial 
of that class of remedies of whose mode of ope- 
ration we are ignorant, and which have been de- 
nominated specifics. In certain cases, means of 
this kind have certainly had excellent effects. 
After the ample discussion given to the more gen- 
eral method of treatment, we cannot here enter 
upon any detailed statement of these effects ; 
much less can we attempt any explanation of their 
mode of action. A consideration of the various 
nature and numerous complications of angina, as 
detailed in the preceding pages, will show that 
remedies of this class may possibly possess very 
different powers and modes of action, and yet lead 
to the same results. Bark, iron, arsenic, nitrate 
of silver, the salts of copper, zinc, and other medi- 
cines both of the vegetable and mineral kind, have 
been frequently employed. In a few instances, 
narcotics, such as hydrocyanic acid, belladonna, 
&c, have been found useful. In those eases in 
which the paroxysms approach nearest to the 
purely neuralgic character, remedies of this kind 
hold out the greatest prospect of success. If there 
is any reason to suspect a malarious origin or 
complication, bark, or rather quinine, will be found 
most efficient. In other cases steel and arsenic 
will deserve the preference. Of all the prenara- 



ANODYNES. 



117 



tions of iron, the common carbonate and the sul- 
phate seem the most powerful in nervous diseases. 
The former must be given in large doses, as from 
a scruple to a drachm, several times a day. When 
the stomach and general system were in a proper 
state for their reception, we have found these 
medicines frequently of much benefit in diseases 
of the heart, whether organic or sympathetic ; 
and they have often been found to mitigate, if not 
remove, the attacks of angina. The salts of cop- 
per have also been often tried ; we are not, how- 
ever, aware of any very successful result having 
been obtained from their use. Arsenic and zinc 
have been productive of more benefit. Several 
cases, evidently relieved or cured by these salts, 
are recorded by authors. A well-marked case of 
angina, cured by Fowler's solution, has been pub- 
lished by Mr. Alexander, (Edin. Med. Comment. 
xv. 373 ;) and another cured by white vitriol is 
given by Dr. Perkins, (Mem. Med. Soc, Lond. iii. 
580.) The great length to which this article has 
already extended prevents us from entering into 
fuller details. The reader who has studied the 
pathology of angina can have no difficulty in 
knowing when to apply specific remedies, and 
which ought to have the preference. 

John Forbes. 

[ANIMAL MAGNETISM. (See Somnambu- 
trsjr.) 

ANIMATION, SUSPENDED. (See 
Asphyxia.)] 

ANODYNES. The word anodyne takes its 
origin from the Greek, a, privative, and hbivn, pain ; 
and the literal meaning is, a remedy vjhich re- 
moves pain. The term anodyne is often used 
synonymously with the terms narcotic and seda- 
tive ; but as these three words are all different in 
their strict signification, it is obviously right to 
confine the employment of each of them to its 
proper acceptation. In a work like this, an im- 
portant end is answered by taking up, as distinctly 
as possible, the subject which is suggested by the 
word which stands at the head of each article ; 
and on this account narcotics and sedatives will 
not be particularly mentioned in this place, al- 
though they are generally classed with anodynes, 
as remedies which produce a similar effect on the 
animal body. 

When the practitioner wishes to relieve pain, 
he ought to ascertain, if possible, in the first place, 
what is the cause of the pain. The sensation of 
pain seems to be essentially connected with the 
operation of the nervous system : it may arise, 
1st, from an undue degree of pressure being made 
upon the nerves, or from an injury sustained by 
external violence : 2dly, from increased sensibil- 
ity in the nerves themselves ; so that the pressure 
of external objects, which, under ordinary circum- 
stances, only produces the proper sensation of 
t^uch, or as in some parts, even no sensation at 
all, gives origin to a painful sensation. This in- 
creased sensibility may be the result of many dif- 
ferent causes, e. g., of morbid structure or of mor- 
bid function of the brain, or of the spinal marrow, 
or of the nerves themselves. When this increase 
of sensibility occurs, pain may only be felt when 
external pressure is applied, and then it is denomi- 
nated tenderness; or the pain may be felt inde- 



pendently of such pressure. It is very probable 
that in some painful diseases there is nothing mor 
bid except the function of the nerves themselves , 
no organic alteration, no inflammation, being dis- 
coverable either before or after the death of the 
patient. Pain in such cases is commonly called 
neuralgia. It occurs sometimes in paroxysms, 
leaving intervals of ease more or less complete ; 
sometimes it is constant. Tic douloureux and the 
periodic face-ach are instances of this species of 
disease of the nerves. 

We know very little of the real nature of sen- 
sation. The opinion of Dr. Cullen, that a subtile 
fluid pervades the nervous system, that this fluid 
is thrown into motion by the application of cer- 
tain agents, and that thus sensation is produced, 
is too conjectural and vague to be adopted by any 
modern physiologist : the same may be said of all 
other known hypotheses on this subject. It must 
therefore clearly appear impossible to afford a sat- 
isfactory explanation of the real nature of the sen- 
sation of pain. Probably that peculiar property 
of the nervous system which we denominate sen- 
sibility, or the capability of feeling, becomes so 
increased, in some instances, as to produce, by 
itself, the sensation of pain (these would be called 
instances of neuralgia) ; yet in other cases the 
sensibility in the nerves seems to be increased and 
pain produced by certain appreciable changes in 
the condition of the part which is the seat of the 
pain ; and this may be illustrated by what occurs 
in inflammation : pain being almost the constant 
accompaniment of the other symptoms. On ex- 
amination of the different parts of the body in 
their natural condition after death, those which 
are the most sensible to the touch are found to be 
more plentifully supplied with blood-vessels as 
well as nerves ; as, for example, the ends of the 
fingers and the lips ; both of which parts may be 
considered as instruments of touch : and it ap- 
pears that the large supply of blood sent to them 
is more than sufficient for the process of nutrition. 
This fact, taken in connection with another, which 
has been a matter of frequent observation — viz., 
that when the flow of blood to these parts is in- 
terrupted, without any injury having been done 
to the nerves themselves, numbness to a certain 
extent is the consequence, — leads us to conclude 
that the sensibility of a nerve bears some propor- 
tion to the quantity of blood circulating in the 
capillary blood-vessels in connection with it. We 
should therefore expect, that when, as in the case 
of inflammation, a larger quantity of blood is thrown 
into these vessels, an increase of sensibility of the 
nerves would be the consequence. Many physio- 
logical and pathological facts might be adduced in 
corroboration of the opinion just stated ; but 
enough probably has been said to answer the pre- 
sent purpose, which is to show that the increased 
sensibility of a part in inflammation depends very 
much on the increased determination of blood to 
the part inflamed. 

Besides external violence and increased irrita- 
bility of the nerves, either connected with or inde- 
pendent of inflammation ; inordinate contraction 
of the muscles, or spasm, must be mentioned 
among the causes of pain, and of pain, too, some- 
times of the severest kind. The probable expla- 
nation of the production of pain by spasm .? 



118 



ANODYNES. 



afforded by the circumstance of the pressure which 
must lie made upon the nerves by the contracting 
muscular fibre, and must give origin to excessive 
sensation. Of course when the nerves are ren- 
dered morbidly sensible by inflammation, or by 
any other cause, the pain from spasm will be more 
seveie. Many facts warrant the conclusion that, 
in some morbid conditions of the. body, excessive 
sensibility of the nerves and muscular spasm often 
co-exist, as essential parts of the same disease. 
It would not be in place to inquire here whether 
the sentient nerves, or the nerves of muscular 
motion, or whether both, are those affected when 
pain is produced by spasm : indeed it seems to be 
a point which we cannot determine, and probably 
we should derive no practical advantage from the 
knowledge were we able to gain it. 

Pain may be alleviated or subdued, 1st, by the 
removal of the remote cause, such as inflamma- 
tion, spasm, external pressure, &c; 2dly, by the 
employment of remedies which reduce the degree 
of the sensibility of the nerves ; and, 3dly, by the 
employment of remedies which render the brain 
so torpid as not to allow the patient to feel the 
effect of the usual causes of pain when they exist. 

On the first of these heads very little need be 
said in this place: indeed, the general means 
which ought to be employed for the removal of 
the diseases which are attended with pain cannot 
be properly classed among the remedies which are 
Btrictly called anodynes, although pain, along with 
the other symptoms of such diseases, is removed 
by them ; it may however be, with propriety, re- 
marked, that in such diseases as inflammation and 
spasm, the pain may often be suspended during 
their continuance by the medicines which are 
strictly called anodynes, i.e., medicines -which re- 
duce the sensibility of the nerves, or produce a 
torpor of the brain, and that it may occasionally 
be very desirable to administer them for that pur- 
pose. In spasm, indeed, the same remedies which 
-ire calculated to allay pain, will frequently also 
allay the inordinate action of the muscular fibre, 
(vide Antispasmodics ;) and in many cases of 
painful disease, anodynes may, by deadening the 
patient's feelings, prove auxiliaries to those reme- 
dies which are given with a more direct view to 
the removal of the disease itself; for as the sen- 
sation of pain frequently acts upon the system as 
a kind of irritant, so the suspension of that sen- 
sation by means of an anodyne, may, in many 
diseases of excitement, allow such diseases to 
come more completely under the operation of the 
remedies which may be administered to subdue 
inordinate action. In many instances too, the 
comfort of patients may with propriety be consult- 
ed, and their sufferings soothed by the employ- 
ment of anodynes, when they are not contra-indi- 
cated, in diseases of a painful nature. Besides.it 
is necessary, in many diseases attended with pain, 
to endeavour to procure sleep, and this can be 
«nly done by the suspension of pain j for pain is 
a common cause of watchfulness, and for this pur- 
pose anodynes are frequently our only resource. 

The exhibition of anodynes in inflammation, 
however, requires the exercise of much judgment. 
This remark appears to be the more necessary, 
'lecause the employment of some of them, espe- 
cially of opium and the prussic acid, has been of 



late strongly recommended as antiphlogistic re- 
medies : whether they are antiphlogistic or not is 
not now a question for our consideration, the pre- 
sent object being to guard the practitioner against 
their indiscriminate employment in inflammation. 
Pain, or tenderness, is one of the most unequivo- 
cal signs of the existence of inflammation, when 
taken in connection with its other symptoms ; and 
during the treatment of inflammation, when no 
anodynes have been employed, the continuance 
of the pain will often afford an indication, to the 
practitioner, that further active measures are ne- 
cessary : but it is quite certain that inflammation, 
in a considerable degree, may be going on while 
all feeling of pain is suspended by the effect of 
an anodyne ; so that in such a case the indication 
of pain will be lost, the disease may be rendered 
obscure, and the treatment inert. Besides the 
reason just assigned for caution in the employment 
of anodynes, the stimulating quality which some 
of these remedies possess, ought to put the prac- 
titioner on his guard against the indiscriminate 
use of them when treating inflammation. It ap- 
pears better, then, for the purpose of relieving 
pain, to depend generally on the means calculated 
to lessen or remove the inflammation itself, at 
least in all recent and active cases : this must be 
considered the most judicious mode of easing the 
feelings of the patient ; but instances are daily 
met with in practice, especially of chronic inflam- 
mation, where the suspension of pain by ano- 
dynes is indicated by the considerations which 
have already been assigned. 

The medicines which are strictly called ano- 
dynes, act either by reducing the sensibility of the 
nerves, or by rendering the brain so torpid that 
painful feelings are not noticed. It may be fairly 
questioned whether these medicines, when they 
are administered by the stomach, do not all pro- 
duce their effects in the same manner, by reducing 
the sensibility of the whole nervous system, and 
by thus rendering it less susceptible of feeling ; — 
all of them, when carried to a sufficient extent, 
cause the brain to become torpid, and conduce to 
sleep ; and therefore they are not only placed on 
the list of anodynes, but also on that of narcotics. 
It is not, however, to the production of sleep that 
their anodyne quality is to be solely referred, be- 
cause, not unfrequently, perfect ease from pain is 
enjoyed by a patient through their instrumentality, 
although the mind is as wakeful as ever. When, 
however, these remedies are applied locally to 
painful parts, the action may be entirely local ; 
although when long applied in that manner, or 
applied in large quantity, they will sometimes 
show an effect on the brain, and it would be too 
much to assert positively that their action is in 
any case entirely local. 

As a morbid degree of sensibility seems some- 
times by itself to constitute a painful disease, the 
employment of anodynes may be occasionally re- 
quired as the principal means for the cure of such 
disease : for this purpose it will be generally ne- 
cessary to continue them for some length of time. 

The following is a list of anodynes which are 
most commonly used. 

Opium. 

Hyoscyamus niger, (Henbane.) 

Atropa belladonna, (Deadly nightshade.) 



ANTHELMINTICS. 



119 



Conium maculatum, (Hemlock.) 
Datura stramonium, (T/iornapple.) 
Acidum hydrocyanicum, (Prussic acid.) 
The doses and modes of administering these 
remedies will be mentioned under the article Nar- 
cotics. Some others also will be there noticed, 
which are occasionally employed as anodynes as 
well as narcotics ,■ for whatever produces torpor of 
the brain and sleep, must, in accordance with the 
views already given, be capable of alleviating 
pain. Certain other articles of the Materia Me- 
dica, besides narcotics, occasionally suspend pain, 
and may therefore be considered anodyne in their 
operation. These are the ferri subcarbonas, cin- 
chona cortex, and the arsenicum album. It is 
undoubtedly true that these are efficacious reme- 
dies in many painful diseases ; but it is very ques- 
tionable whether they ever act directly on the sen- 
sibility of the nervous system ; they appear rather 
in such instances to be capable of suspending the 
morbid action on which the increased sensibility 
and pain depend, and therefore, strictly speaking, 
the application of the term anodyne to them does 

not appear proper. , ,, 7 

11 ^ l John Whiting. 

ANTHELMINTICS.— This term is applied 
to substances intended to destroy, and to expel 
from the body, intestinal worms. [The defini- 
tion ought also to be extended so as to embrace 
agents that prevent their generation. The great 
object, indeed, is to remove the predisposition to 
their generation. The anthelmintics that destroy 
or expel, merely remove the parasites already pre- 
sent in the alimentary tube ; but unless the patho- 
logical condition that gives occasion to their re- 
production is removed, the evil will constantly 
recur.] In order to acquire a full knowledge of 
the manner in which these substances operate, 
and of their practical utility, we ought to make 
ourselves familiar with the natural history of in- 
testinal worms ; but as this information is given 
under a distinct head in this work, we shall con- 
fine our remarks, in the present article, to the 
means of relieving the body from these parasitic 
inimals. 

The remedies belonging to this class of the 
Materia Medica are various, and on this account 
we regard that arrangement the most usci'ui, .a a. 
practical point of view, which refers to the*, r.ode 
cf operation. The whole class may oe enveni- 
ently arranged under three heads :--(<)\Mant an- 
thelmintics ; bptJ.jic anthelmintic. ; corroborant 
anthelmintics. 

I. Evacuant anthelm.niLf; are substances 
which dislodge and expel v/crrns from the intes- 
tinal canal, whether by i mechanical, a chemical, 
or a cathartic action. 

1. Among those euxuant anthelmintics which 
operate mechanica/iy, we consider two prepara- 
tions only worthy of notice, — granulated metallic 
tin, and the seta? jf the pods of the dolichos pru- 
riens. Tin, sta/mum, appears to have been used 
as an anthelmintic, in combination with common 
salt and some other purgatives, by Paracelsus ; 
(Opera Medico-Chemica. Liber de Preparatio- 
nibus) ; and it is mentioned also by Quincy, 
(Quincifs Pharmacop. p. 246,) as a vermifuge; 
but it was particularly introduced to the notice of 
the profession, in 1736, by Dr. Alston, (Alston's 



Lectures on the Mat. Med. vol. i. p. 150,) who 
prescribed it, for the first dose, to the extent of 
an ounce, mixed in treacle ; for the second, which 
was not administered until three days after the 
first, half that quantity ; and then finished by giv- 
ing a purgative, which generally brought away the 
worms. It is now prescribed in much smaller 
doses ; not more than a scruple, or at most a 
drachm being given for a dose ; but this is repeated 
three or four times a day for four or five succes- 
sive days, and is followed by a brisk cathartic. 
We have found it useful chiefly in those cases in 
which the ascaris lumbricoides was present. Lewis 
and many others erroneously attribute the benefit 
derived from this employment of tin to the arsenic 
which it frequently contains ; others ascribe it to 
the tin being solvent in the gastric juice, and thus 
forming hydrogen gas, which is poisonous to the 
worms ; an opinion which is supposed to be sup- 
ported by the efficacy of the aurum musivum, sul- 
phuretted oxide of tin, which was formerly much 
employed as an anthelmintic. In France a nearly 
similar opinion of the poisonous nature of tin is 
maintained ; for wine exposed in tin vessels is 
prescribed as a vermifuge. One forcible argu- 
ment against these opinions is derived from the 
fact that the worms are generally voided alive ; 
and there can be very little doubt that the benefit 
is derived solely from the mechanical irritation of 
the worms by the grains of the tin — an opinion 
which is rendered more probable by reflecting on 
the manner in which lumbrici dispose themselves 
in the canal. " The dissection of one subject has 
shown me," says Mr. Rumsey, " that they dis- 
pose themselves in the most curious and tortuous 
form, such as I thought exactly adapted to th& 
exertion of' their muscular power against opposite 
sides of their cylindrical abode, resisting, by this 
means, the effect of the propelling motion of the 
canal, and thus keeping their station. An illus- 
tration of this mode may he found in the art em- 
ployed by a chimnfey -sweeper to counteract the 
effects of gravkation by pressing against opposite 
sides a\ th» cylinder in which he exerts his skill." 
(iVlvdko-Chirurg. Trans, vol. ix. p. 401.) The 
Lrri ation excited by the tin prevents them from 
.etaining this position, and causes them to he 
easily expelled. The other mechanical agent well 
adapted for expelling the round worm, ascaris 
lumbricoides, is cowhage, dolichos pruriens- 
cuna, of the Pharmacopoeia of the United States, 
1842,1 — a very common anthelmintic in the West 
Indies. The setse on the outside of the pods are 
scraped off, after sheathing them by dipping the 
pods in syrup, and then formed into a kind of 
electuary, which is given in doses of one or more 
teaspoonfuls, early every morning, for three suc- 
cessive mornings ; this is followed by a brisk ca- 
thartic. The setae, in the same manner as the 
tin, wound and irritate the worms, obliging them 
to leave their hold on the coat of the intestine, — 
at least this is the usual opinion of their mode of 
acting. A dessert-spoonful of the electuary is 
given to an adult, fasting, for two successive 
mornings : many worms are usually evacuated 
after taking the second dose, particularly if the. 
long thread worms be present. The cathartic is 
generally requisite to aid their expulsion, and if 
it consist of calomel and scammony, any ascan.Ies 



120 



ANTHELMINTICS. 



present in the rectum are expelled at the same 
lime. Neither the powder of tin nor the cowhage 
are now so generally employed as they formerly 
were. 

[The short, stiff bristles on the tube which ter- 
minates the coriacious and scaly involucre or cu- 
pula that surrounds the nut of corylus rostra/a, 
1 beaked hazel,' have been found to possess similar 
virtues to those of mucuna. They may be 
given in the same vehicle and doses. (Amer. 
Journal of Pharmacy, Jan. 1843; and Dungli- 
son's New Remedies, 4th edit. p. 200 : Philad. 
1843.)] 

2. The chemical anthelmintics of this (the 
evacuant) division operate in two ways ; either 
purely chemically, by dissolving the viscid mucus 
or slimy secretion in which the worms are in- 
volved ; or, besides doing so, also by stimulating 
the mucous membrane, and by improving the 
nature of the secretion, preventing the accumula- 
tion of the slime. Lime-water and pure alkalis 
may be regarded as almost simple chemical ver- 
mifuges ; the former is perhaps more useful, espe- 
cially for removing the ascarides, when it is ad- 
ministered as an enema. When taken into the 
stomach, the dose should not be less than four 
ounces ; and it is useful to combine it either with 
infusion of gentian or of chamomile flowers. If 
the solution of the alkalis, or their carbonates, be 
employed, the dose should be carried to its utmost 
extent, beginning with small doses ; for example, 
from twenty to thirty minims, and gradually in- 
creasing the number of minims daily until two 
drachms or more be taken twice a day. The 
alkalis also may be given in bitter infusions, that 
of tansy for instance, and combined with some 
essential oil in the form of an oleo-saccharum. 

3. The purgative anthelmintics have no other 
effect than clearing away the superabundant mu- 
cus, and such worms as are detached from the 
coats of the intestinal canal, and can be expelled 
in conjunction with the mucus. Amongst the 
saline purgatives, common salt and sulphureous 
waters, such as those of Harrogate, have been 
found most useful. The common salt combines 
a tonic with its purgative property [and is positively 
detrimental to entozoa when they are out of the 
body]. It may be given in doses of a scruple to 
an ounce dissolved in a large quantity of water, 
or double the quantity may be exhibited in the 
form of enema, when the rectum is much infested 
with the ascarides vermiculares. The Harrogate 
water, besides purging, operates as a poison to 
the worms by the evolution of the sulphuretted 
hydrogen gas which it contains. Rhubarb, scam- 
mony, and colocynth, [castor oil, and croton oil] 
operate as simple evacuants ; and, for the same 
reason, gamboge is sometimes employed : they are 
generally ordered with a view of operating as 
cathartics after the employment of other anthel- 
mintics. One of the most common of the means of 
expelling worms in children is to give a large dose 
of calomel at bed-time, and on the following morn- 
ing an ample dose of scammony with sulphate of 
potassa : a large portion of bile is thus brought 
down into the bowels, which aids greatly in dis- 
charging the mucus of the inteslines. In the 
;ases of children, indeed, active purging is borne 
■vith much less inconvenience than in those of 



adults ; and the first object is always to effect as 
much as can be done by cathartics, and then to 
have recourse to other means. 

II Specific anthelmintics are substances which 
destroy the worms by some poisonous principle, 
The Materia Medica is rich in such articles, but 
many of them have been overrated, and are little 
worthy of notice ; we shall, therefore, bring before 
otir readers those only which experience has as- 
certained to be valuable. The rectified oil of tur- 
pentine, the best of these specifics, was introduced 
into practice by Dr. Fenwick, for the destruction 
of the tape-worm. It is usually given in doses 
of a fluid ounce, or an ounce and a half, which 
sometimes produce sickness and purging, and 
occasionally intoxication, but rarely tenesmus or 
strangury ; for in large doses its cathartic influ- 
ence evidently stands in the way of its absorption, 
and prevents, in particular, its effects on the urinary 
passages. In some habits large doses cause a sen- 
sation of chilliness and a tendency to sleep ; this 
has been, in some instances, partially obviated by 
administering the oil soon after a meal. In al- 
most every case treated with oil of turpentine 
which has come under our notice, the worm has 
been expelled lifeless, and of a livid hue ; the 
poisonous quality of the oil on these parasites is 
therefore obvious. In a few instances we have 
had occasion to aid its purgative effects by castor 
oil, which appears to answer extremely well ; in- 
deed this oil has been lauded by Drs. Odier and 
Dunant, of Geneva, as a specific in taenia. 

The beneficial effect of oil of turpentine in 
taenia led to its employment as a remedy for the 
destruction of other worms. In the hands of Mr. 
Rumsey and others, it has been found very suc- 
cessful in cases of lumbrici, when given in smaller 
doses. To a child of about three years of age, it 
was given in doses of half a drachm, mixed with 
four drachms of thin mucilage of gum arabic, 
twice or three times a day ; and " continued a 
week, with some interruptions, within which space 
one hundred and twenty, mostly full grown, lum- 
brici were brought away."* It has also been pre- 
scribed in the form of enema, to the extent of half 
a fluid ounce sheathed with mucilage of starch, 
for removing the common ascarides from the reC' 
turn ; some caution is requisite in this mode of 
using it; but when it can be administered, the 
worms are discharged in great abundance. 

[Animal oil, DippeVs oil, which is identical 
with the oleum cornu cervi, or oil of hartshorn 
of the older Pharmacopoeias, is highly extolled, by 
the Germans more especially, and it is unques- 
tionably very efficacious, even in cases of trenia ; 
but it is exceedingly nauseous, and few stomachs 
can retain it. Its dose is from five to twenty 
minims, in molasses, for three mornings in suc- 
cession, — following up the last dose by a brisk 
cathartic. 

The empyreumatic oil of Chabert, made by 
adding one part of animal oil to three parts of oil 
of turpentine, leaving them to combine for four 
days, and then distilling three parts, has also been 
greatly praised as an anthelmintic. It, likewise, is 
very nauseous ; but it is very effective, in the dose 



* Trans, of the Mediro-Chirurg. Society of London, 
vol. ix. p. 403. 



ANTHELMINTICS. 



121 



of a teaspoonful, in molasses, two or three times a 
day.] 

The powerful poisonous influence of tobacco on 
animal life has induced some practitioners to em- 
ploy it as a vermifuge in cases of ascarides : it is 
thrown into the rectum, both in the state of in- 
fusion of the dried leaf, or as smoke. In either 
form, the danger attending its employment is suf- 
ficient to cause its rejection from the list of an- 
thelmintics. 

The root of the male fern was employed as an 
anthelmintic as early as the time of Dioscorides : 
it was afterwards neglected, and occasionally re- 
vived, until the success of Madame Nouffler's 
practice, in the eighteenth century, established its 
reputation as a remedy for tape-worm. According 
to Madame Nouffler's directions, three drachms of 
the powdered root were given in the morning, 
xfter the patient had been prepared by the exhibi- 
tion of an enema on the preceding night ; and 
two hours after the dose of the fern-root had been 
taken, a bolus, consisting of twelve grains of 
calomel, twelve of seammony, and five of gam- 
boge, was also administered. This practice proved 
frequently successful ; but, with Cullen, many 
practitioners have attributed the benefit chiefly to 
the purgative ; an opinion, however, which has 
been shaken by the analysis of the fern-root by 
M. Peschier, of Geneva, who discovered in it a 
volatile oil to which he attributes all its activity. 
Thirty drops of this oil are equal to three drachms, 
or a full dose, of the powder : it may be given 
either in the form of an oleosaccharum made into 
an emulsion with almond mixture, or of pills 
made with crumb of bread. One half of this 
dose is given at bed-time, and the other half on 
the following morning, on the empty stomach ; 
and if it do not purge, a dose of castor oil should 
be given in the afternoon of the same day. The 
success of M. Peschier with this oil appears to 
have been considerable, and has been confirmed 
by the experience of others. In every instance 
the worm was voided lifeless ; whence we may 
infer the accuracy of the opinion, that it is this 
oil which acts as a poison when the powder of 
the fern-root is administered. [See Dunglison's 
New Remedies, 4th ed., p. 312 : Philad., 1843.] 

The bark of the geoffroya inermis, or bastard 
cabbage-tree of Jamaica, and the powdered roots 
of the Indian pink, spigelia Marj/landica, have 
been stated to be as certain anthelmintics for the 
removal of lumbrici as the oil of turpentine and 
the male fern for that of taenia. The former was 
introduced to the notice of the profession by Mr. 
Duguid, of Jamaica,* and was much extolled by 
Dr. Wright, who published the botanical charac- 
ters of the plant. (Phil. Trans, vol. lxxviii. p. 
507.) The best form of exhibiting it is that of 
decoction, made by boiling an ounce of the bruis- 
ed bark in two pints of water, down to a pint. 
The dose for an adult is two fluid ounces, which 
generally purge, producing also a slight degree of 
nausea ; but if cold water be drunk during its 
operation, violent vomiting and much fever super- 
vene, which, however, are quickly relieved by 
purging with castor oil, and the free administra- 
tion of warm water a cidulated with a vegetable 

* K-says, Physical and Literary, by a Society in Edin- 
burgh, 8VO. 1770. vol. ii. p. 230. 

Vol. I.— 1G i 



acid. Although the active principle of this bark 
is still unknown, it is very evident that it operates 
as a specific poison to the worms ; and this opin- 
ion is confirmed by the fact, that, when it is tardy 
in its operation, and requires the aid of a purga- 
tive, its anthelmintic effect is more decided. It is 
seldom employed in England. 

The Indian pink appears to operate in its re- 
cent state as a narcotic, unless it be given in doses 
sufficiently large to secure quickly its cathartic 
influence ; but in the dried state in which it is 
usually found in this country, its narcotic pro- 
perty, if it possess any in this state, is exhausted 
in the destruction of the worms, as we have never 
perceived its effects on the system of the patient. 
It is administered in powder, in doses of from ten 
grains to a drachm ; but as far as our experience 
has gone, it requires the aid of some other purga- 
tive to secure its anthelmintic influence in mode- 
rate doses ; and the violent effects of a large dose • 
are too hazardous to be recommended. 

[It is much used in the United States as an 
anthelmintic. Dr. Wood, indeed, thinks that it 
stands there .at the head of the anthelmintics. 
(Dispensatory of the United States, 5th edit., p. 
682: Philad., 1843.) It is certainly highly 
esteemed by many practitioners ; but others have 
equal confidence in chenopodium, and much more 
in oil of turpentine and its combinations. 

The bark of the root of pomegranate (Granati 
Radicis Cortex, Ph. U. S.) has been much used 
in taenia ; but the testimony in regard to it is dis- 
cordant. It is almost always given in decoction, 
which may be prepared with two ounces of the 
bark, boiled in a quart of water down to a pint 
and a half. Of this, the dose is two fluid ounces 
every half hour, until the whole is taken. (Dun- 
glison's Nevj Remedies, edit, tit., p. 332 ; and his 
General Therapeutics and Mat. Med., i. 211 : 
Philad., 1843.) 

The seed of Chenopodium Anthelminticum — 
' wormseed' — chenopodium of the Pharmacopoeia 
of the United States — is one of the most popular 
anthelmintics. The common mode of prescribing 
it, to a child three or four years of age, is to mix 
one or two scruples of the powder with molasses ; 
administering this for three nights in succession, 
and directing a cathartic on the following morn- 
ing. The distilled oil, oleum chenopodii, or worm- 
seed oil, is officinal in the Pharmacopoeia of the 
United States. It is administered in the same 
manner as the powder, in the dose of from four to 
eight drops, mixed with sugar or molasses. 

The wormseed of Europe is the fruit of Arte- 
misia Santonica, or of a variety of A. maritima.] 

The only other anthelmintic of this division 
which requires notice, is one which has been very 
seldom, if ever, employed in this country ; and 
we bring it before our readers only because we 
have seen its active principle, veratria, operate in 
expelling lumbrici, when it has been administei 
ed, with another intention, in the form of wint> 
of colchicum. The seeds of the veratrum saba 
dilla, the substance to which we refer, have been 
long celebrated on the continent as a specific in 
trenia lata, and are much extolled by Seeliger and 
M. Brewer. The latter prescribed the powdered 
seeds in doses of three grains, which were taken 
on an empty stomach in the morning, for eight 



122 



ANTHRACION — ANTIPHLOGISTIC REGIMEN. 



successive days; and these, on the ninth day, I 
were succeeded by a strong dose of gamboge and 
valerian. It is not easy to explain the beneficial 
effects of this plan of treatment without referring 
it to the veratria, which, hesides acting as a direct 
poison to the worm, stimulates the gall-ducts, and, 
bringing a large portion of acrid bile into the 
duodenum, sweeps out the dead worms. In this 
manner we have seen the wine, and the other 
preparations of colchicum, operate, in expelling 
lumbrici ; but we have had no experience of their 
influence in henia. 

III. It only remains to notice the last division 
of this class of medicines, corroborant anthel- 
mintics. All the substances, in the first divisions, 
act merely upon the worms already existing in 
the intestines, either destroying them or expelling 
them in a living state ; thence the necessity of 
adopting means for preventing their recurrence ; 
and as debility favours their production, it is obvi- 
ous that tonics are indicated. All the bitters may 
be employed for this purpose, but the chalybeates 
have with much reason been preferred. At one 
time it was supposed that the preparations of iron 
are poisonous to worms, an opinion founded upon 
the observation that the earth-worm dies when 
submersed in chalybeate solutions : but the fact 
that the earth-worm respires by the skin, which 
is not the case with intestinal worms, was over- 
looked ; and it is now generally admitted that the 
chalybeates operate as anthelmintics by their tonic 
influence, strengthening not only the alimentary 
canal, but the whole system. Among the prepa- 
rations of iron, the sulphate was extolled by 
Boerhaave, who gave it to the extent of a drachm, 
dissolved in a pint of water, in divided doses, 
within twenty-four hours. We have found the 
milder preparations, particularly the tartarized 
iron operate more favourably with children and 
females, who, as we have already said, are the 
chief subjects of worms. After clearing the 
bowels with a large dose of calomel and scam- 
mony, we prescribe the tartarized iron, in doses 
of a fluid drachm of the solution, to be taken 
three times a day ; but the wine of iron, in simi- 
lar doses, or the tincture of the acetate of iron, 
of the Dublin Pharmacopoeia, in doses of fifteen 
or twenty drops, given in milk, will answer the 
same purpose. In cases of ascarides, chalybeate 
water, such as that of Tunbridge, has been found 
to be extremely useful when administered as an 

enema. , m ^ 

A. T. Thomson. 

[ANTHRACION (from avOpa^ < a coal'). This 
affection has an extensive synonymy; — Pustula 
maligna, Vesicula gangrecnescens, Malignant 
vesicle, Malignant pustule, and Persian fire. In 
France it is known under the names, Pustule 
maligne, Feu Persique, Mal-vat, Bouton malin, 
&c. ; and in Germany under that of Milzbrandkar- 
bunkel. It is characterized by the appearance of 
a bleb filled with reddish sero-sanguinolcnt fluid, 
under which a small lenticular induration is 
formed, which is speedily surrounded by diffuse 
inflammation of an erysipelato-phlegmonous cha- 
racter. The inflammation terminates in gangrene, 
wh'ch spieads rapidly from the centre to the cir- 
cumference of the tumour. This is the general 
< haracter of the affection ; but at times a white 



line of demarcation checks its progress: at others, 
the cellular tissue becomes rapidly disorganized, 
and deep caverns form beneath the skin. M ben 
gangrene strikes the central part, the inflammation 
extends to a considerable distance around — the 
skin being red, tense, and shining, and the sub- 
cutaneous tissue swollen, infiltrated, and often 
emphysematous. The affection is generally accom- 
panied by great constitutional disturbance ; and in 
its progress, the symptoms become markedly ady- 
namic, and the patient often sinks and dies within 
the first twenty-four hours from the onset. When 
it terminates favourably, the phenomena are the 
same as in cases of local gangrene in general ; a 
line of separation occurs, and the constitutional 
symptoms improve. 

It is the common belief that anfhracion occurs 
only from the contact of the matter of carbuncle 
of animals. Accordingly, it appears on parts of 
the bodv that are ordinarily or accidentally ex- 
posed. Thus, it is often seen on the face ; never 
on the scalp ; and most commonly on the hand, 
forearm, arm and neck. (Rochoux, Diclionnaire 
de Medecine, torn. 26. p. 510 : Paris, 1842.) It 
would seem, however, that it may originate spon- 
taneously in man. 

The treatment, where the disease is produced 
by the contact of virus, may be divided into that 
which is proper, whilst the affection is entirely 
local ; and into that which is necessary, where the 
constitution becomes implicated. 

The plan thought to be most successful, in the 
first case, is to make incisions through the gan- 
grenous parts, so as to permit escharotics to come 
in contact with the sound textures, and induce in 
them a new action. A strong solution of nitrate of 
silver, from 20 to 40 grains to the ounce of water, 
or liquid muriate of antimony, or diluted or even 
strong muriatic acid, may be applied by means of 
dossils of lint. By some, potassa has been ad- 
vised ; and by others, chloride of zinc. The 
escharotics may remain on a few hours ; after 
which, turpentine dressings, or warm poultices, 
may be substituted. On the next day, if there 
be no appearance of an extension of the disease, 
the soothing treatment may be pursued, or 
poultices, to which aqua chlorini has been added; 
or an ointment of the same ; or a cataplasm or 
ointment of chlorinated lime may be used. The 
internal management must be the same as in gan- 
grenous affections in general. Tonics are de- 
manded ; and opiates may be needed to allay 
suffering. (Practice of Medicine, 2d edit. p. 113: 
Philad., 1844.) 

J KOELEY DCNGLISON.J 

ANTIPHLOGISTIC REGIMEN, (from M, 
contra, and ^Xdyoxrif, inflammatio). The term 
antiphlogistic regimen implies the accessory treat- 
ment required in aid of medical discipline for the 
removal of fever or inflammation. So essential 
is this aid, that neglect of it may render fruitless 
the most judicious course of medical treatment, 
on which account it merits the serious attention 
of every practitioner. 

As the medical treatment of fever and inflam 
mation will be treated of under the proper head* 
it is unnecessary in this article to do more than 
notice the assistant means by which its end mav 
be promoted. These may be considered as thei 



ANTIPHLOGISTIC REGIMEN. 



123 



regard bodily rest, diet, air, temperature, and men- 
tal repose, under which all that is essential may 
be included. 

Bodily rest Fever and inflammation being 

characterised by morbid excitement, which, when 
excessive or unrestrained, is tbe source of much 
injury, and to allay which is the object of medical 
interference, it becomes important to avoid every 
influence by which it might be prolonged or ex- 
asperated. Bodily exertion increases excitement, 
and should therefore be suspended by consigning 
the patient, if not in every instance to bed, at 
least to perfect quietude. Under fever the whole 
muscular system becomes debilitated, and even 
slight exertions are not made without an effort far 
greater than would be required in a state of health. 
During such effort the motions of the heart, al- 
ready too frequent, become still further accele- 
rated i more blood is transmitted to the lungs 
than can find a free passage through them, and 
the breathing is hurried in proportion. Such dis- 
turbance of the important functions of the heart 
and lungs is eminently unfavourable to the objects 
which the physician has in view. Independently 
of locomotion, even the erect posture is not sus- 
tained by a frame debilitated by febrile derange- 
ment without a painful effort, and is badly borne. 
Under febrile or inflammatory diseases requiring 
active treatment, therefore, it is always advisable 
to enjoin perfect rest and a recumbent posture, to 
ensure which the patient should be kept in bed 
in all cases where there is much excitement to 
allay. 

D.'ef. — This requires to be regulated both as to 
quantity and quality. Happily, under fever appe- 
tite pretty generally declines, and the patient is 
thus debarred from taking what would aggravate 
his disorder. The suggestions of nature are always 
worthy of attention, and in no instance are they 
more clearly announced than in the inappetency 
which attends the febrile state. In the exposition 
of fever and of inflammation given in this work, 
it will be seen how completely this disinclination 
for food accords with what our best knowledge of 
fever enjoins. During acute fever or inflamma- 
tion, abstinence is essential ; and so long as they 
continue active, the standard of diet can hardly be 
too low. Simple diluents are all that the stomach 
can bear, or the patient require, and even with 
these the stomach should not be oppressed. So 
powerful is mere abstinence in abating fever, that 
it might almost be laid down as an axiom, the 
more perfect the abstinence, the less will be the 
necessity for medical agency. The remarks here 
made on the quantity of food apply with even 
greater force to its quality. It is familiarly known 
that animal food is more nutritive than vegetable ; 
consequently animal diet must be unsuited to a 
state of disease in which nutritive matter is already 
relatively in excess. However opinions may differ 
on the connexion of fever with an antecedent state 
of plethora, all will agree that under fever the 
ordinary expenditure of nutritive matter in the 
several secretions of health becomes diminished, 
from the secretory functions by which the several 
tissues are nourished failing in their wonted ener- 
gies ; whence the nutriment with which the blood 
is, on the accession of fever, already charged, can 
30 longer be beneficially disposed of, and becomes 



oppressive to the system. To add to the load by 
more diet, and especially by diet so nutritive as 
that which animal matter furnishes, cannot be 
judicious. Nature revolts from it, experience 
condemns its use, and enlightened practice will 
ever withhold it, however importunate friends and 
relatives may be, through mistaken kindness, to 
induce a relaxation of that discipline which the 
judgment of the medical attendant leads him to 
enforce. According as disease declines, greater 
indulgence may, of course, be granted ; but this 
consideration belongs to the medical treatment, 
and is discussed elsewhere. The present article 
professes only to specify what is meant by anti- 
phlogistic regimen when it is enjoined by the 
medical attendant. 

Air — The time is happily gone by when febrile 
patients were immured in heated chambers, over- 
whelmed with blankets, a good fire maintained to 
prevent the risk of cold, and every aperture through 
which pure air could enter, even to the key-hole 
of the door, carefully closed. Absurd and almost 
incredible as this practice now appears, half a cen- 
tury has scarcely elapsed since it was generally 
followed. The febrile sufferer is now allowed to 
breathe a pure atmosphere, to ensure which is a 
most essential part of the antiphlogistic regimen. 
The intelligent practitioner, to whom the elements 
of physics should be familiar, can be at no loss to 
ascertain whether the circumstances of the inva- 
lid's chamber be such as to afford the necessary 
assurance of adequate ventilation. The confine- 
ment of air by closed bed-curtains is particularly 
pernicious, and should be utterly disallowed, the 
use of these being limited to averting direct cur- 
rents, and moderating the glare of light. Even 
light should not be wholly excluded from the sick 
chamber, save where there is high excitement of 
the brain, or morbid sensibility of vision. 

Temperature. — On this head it may suffice to 
state that the best medium temperature for a cham- 
ber is about 60° of Fahrenheit's thermometer. 
Circumstances may occasionally require it to be 
higher or lower. As sensation is a very imperfect 
measure of temperature, the best security is to 
adjust the heat by a thermometer suspended in the 
room. 

Mental repose. — The observations made on bo 
dily rest are all applicable to the state of the mind. 
Mental excitement is capable of disturbing all the 
bodily functions, and of exasperating every symp- 
tom of fever. Of ordinary exertion of mind the 
febrile patient is soon rendered incapable by the 
effects of disease, which speedily hebetate the 
mental energies. The morbid excitement of brain 
which results from its special derangement i>- 
itself a symptom of disease, and, as such, is the 
proper province of the medical attendant, who 
should direct the appropriate treatment ; all ordi- 
nary excitement of mind of which the patient 
may be susceptible should be carefully restrained, 
or permitted only with extreme caution; perfect 
quiescence both of body and mind being that state 
which will best second the medical treatment. 
Indeed, it is the same principle which applies to 
both ; for though in referring to mind the remarks 
are applied to the manifestations, the reasoning is 
really directed not to these, but to the physical 
state of the brain on which they depend, and 



124 



which, under fever, is sensibly disturbed by what- 
ever gives rise to much mental emotion. 

The moral treatment of the invalid is, conse- 
quently, no unimportant part of antiphlogistic 

regimen. ,-, ,-, 

E. Barlow. 

ANTISEPTICS. -See Disinff.ctiox. 

ANTISPASMODICS (ivrl, against, and <rra<7- 
pasm) are usually defined stimulant sub- 
stanccs which allay irregular muscular contrac- 
tion. In whatever manner muscular action takes 
place, it may be affirmed that it is altogether at- 
tributable to the nervous system ; the nerves of 
motion being those engaged in it, whether the 
stimulus or exciting power be mental or material. 
The motion which is induced is transitory, and 
always followed by a state of rest ; it is this alter- 
nation of motion and quietude, under due regula- 
tion, which constitutes the distinction between 
ordinate and inordinate muscular action. If, after 
muscles have contracted, they retain this condition 
when the exciting cause ceases to operate, they 
are said to be in a state of spasm, and such medi- 
cines as have the power of resolving this state are 
termed antispasmodics. If narcotics allay irrita- 
bility, soothe pain, and produce diminished suscep- 
tibility to the impressions of exciting agents, it 
may reasonably be inquired in what respect anti- 
spasmodics differ from narcotics. 

The chief circumstance in which antispasmo- 
dics differ from narcotics is, that the administra- 
tion of the former is not followed by the insensi- 
bility to impressions, and collapse, which almost 
invariably follow the exhibition of narcotic sub- 
stances. ]No such effects can be induced by anti- 
spasmodics, even in large doses ; yet they are as 
powerful as narcotics in repressing inordinate 
muscular action. In explaining, therefore, the 
difference between antispasmodics and narcotics, 
we may hazard the opinion that it is probable the 
impression exerted on the extreme nerves by a 
narcotic is confined to those of sensation, and 
must be communicated to the brain before the 
effect is produced ; whereas that caused by an 
antispasmodic is confined to the nerves of motion, 
and produces an immediate and more permanent 
result by some changes effected in the state of the 
motor nerves, independent of any communication 
with the sensorium. If this opinion be correct, 
antispasmodics, in the strict meaning of the term, 
stand in the same relative position to narcotics as 
astringents to tonics. But, whatever may be their 
mode of action, the distinct nature of an antispas- 
modic, acting simply as such, is very obvious; and 
antispasmodics may be regarded as holding an in- 
termediate place between narcotics and tonics, — 
less diffusible but more durable than the former, — 
more immediate but less permanent than the lat- 
ter. Another point requires consideration, viz., 
whether antispasmodics are to be regarded as sti- 
mulants or sedatives ? If our hypothesis be cor- 
rect, they have a sedative operation ; for if the 
irregular or inordinate action, which they over- 
come, be the consequence of irritation, either men- 
til or corporeal, it follows that, in resolving spasm, 
the susceptibility of impression in the extremities 



ANTISPASMODICS. 

Mediate, or the eonsequcr.ee of a previous stimu- 
lant operation : thence, we can explain the reason 
why some of these medicines which are direc 
„„fi«»«modics stimulate the general system, and 



antispasmodics stimulate tne genen 

consequently quicken the pulse ; smce, ike nar- 
cotics their primary action may be stimulant, and 
quickly followed by collapse. According to tins 
mode of reasoning, the same results may follow 
from the influence of the exclusive operation of 
antispasmodics on the nerves ol motion, as from 
that of narcotics on those of sensation. 

Antispasmodics, as far as regards their mode of 
action, may be divided into direct, or '-those which 
exert their influence on the nervous energy, but 
neither as narcotics or tonics :" and indirect, or 
"those narcotics and tonics which produce an an- 
tispasmodic effect." 

The effects of antispasmodics are generally per- 
ceptible very soon after their administration, more 
especially if the powers of the individual are 
weak. It should, however, be kept in mind that 
this class of remedies is of no avail, indeed is posi- 
tively injurious when the spasmodic muscular ac- 
tion is the consequence of inflammation of the 
brain or spinal marrow : under such circum- 
stances, blood-letting and other measures calcula- 
ted to subdue the primary disease, are the proper 
measures to be adopted. It is necessary also to 
mention that the operation of antispasmodics is 
very transient, and that by frequent repetition their 
influence on the nervous system is much impaired; 
the dose therefore requires to be modified very 
much, according as the individual has or has not 
been accustomed to their employment. 

The Materia Medica furnishes few direct anti- 
spasmodics. One of the most powerful, musk, is 
too expensive to be generally prescribed, particu- 
larly as the dose is required to be very large in 
order to obtain a satisfactory result from its em- 
ployment. We can bear testimony to its power- 
ful influence in diminishing the violence of the 
paroxysms of idiopathic epilepsy, and greatly 
lengthening the intervals, when the dose is carried 
to the extent of a drachm given at intervals of 
eight hours. It is most advantageously prescribed 
in the form of bolus : the mixture and the tinc- 
ture of the Pharmacopoeias being very uncertain 
preparations. Much less can be said in favour of 
castor, which is greatly inferior to musk as an 
antispasmodic. 

Among the animal oils, that of Dippel, although 
much lauded on the continent, and notwithstand 
ing its success in epilepsy in the hands of Alibert, 
may be regarded as an antispasmodic of little effi- 
cacy, and ought to be expunged from the list of 
Materia Medica. The oil of amber, also, formerly 
prized as a powerful antispasmodic, is now scarcely 
ever prescribed. Valerian, assafectida, galbanum, 
and sagapenum, owe their antispasmodic properties 
chiefly to volatile oil, in combination with resin 
and extractive matter : their efficacy in hysteria, 
spasmodic asthma, and similar affections, has been 
well ascertained. Naphtha was formerly much 
employed as an antispasmodic in diseases unat- 
tended with inflammatory symptoms ; and the 
West Indian practitioners still extol it in hooping- 



o f the motor nerves must be diminished, and this cough, and some other spasmodic diseases. 

can only be the result of a sedative power. It With respect to indirect antispasmodics, little is 

Uiav, however, be affirmed that this may be either , required to be said. In selecting them we must 



ANTISPASMODICS. 



125 



be guided by the state of the patient, and the 
nature of the exciting causes of the spasms which 
we are called upon to relieve. If they are the 
result of local irritation, and kept up by habit after 
the removal of the irritating cause, narcotics are 
to be employed as the most powerful means of 
allaying irritation, and breaking the habit which 
has been acquired. But if the spasm is maintain- 
ed by a peculiar susceptibility to impressions, 
which is always, more or less, connected with 
debility, then tonics are to be administered ; and 
the more rapidly the body can be brought under 
their influence, the better. 

Something may be expected to be said with re- 
gard to mental impressions as antispasmodics. 
There can be no doubt that some mental states 
produce and maintain spasmodic action in the 
body, while others as readily operate as powerful 
antispasmodics. As a minute consideration of 
this question, however interesting in itself, would 
exceed our limits, we shall merely allude to the 
power of abstraction. In every instance of spas- 
modic action, from whatever cause, the attention 
is directed to the part affected ; so long as this 
exists, no corporeal agents which do not make a 
greater impression on the mind than that pro- 
duced by the spasm, can resolve it : but when the 
attention is withdrawn from the spasm, it is in- 
stantaneously relaxed. Thus, a man has his 
shoulder-joint luxated ; and, after various attempts, 
the luxation cannot be reduced on account of 
spasm which has supervened, and which is main- 
tained by the attention of the patient being direct- 
ed solely to the part ; but abstract the attention, 
and the spasm instantly yields, and the head of 
the humerus slips into the socket. In the same 
manner, and with the same success, the antispas- 
modic influence of abstraction has been experi- 
enced in hernia and other diseases ; in its appli- 
cation, however, great judgment and nice discri- 
mination are requisite. 

In reference to the practical employment of 
antispasmodics, their utility is confined to one 
order of diseases only, the spasmi. In tetanus, 
the narcotic antispasmodics, particularly opium 
and camphor, have been much employed ; but 
neither these nor the direct antispasmodics, musk, 
oil of amber, or assafcetida, have fulfilled the 
anticipations of practitioners. The most power- 
ful is, undoubtedly, opium ; and it is almost in- 
credible what doses of this remedy may be ad- 
ministered in this disease ; fifteen and twenty 
grains have been given every three hours, for 
eight and ten days successively, with little effect 
upon either the disease or the constitution of the 
patient. When opium has proved beneficial, its 
effects have been rarely obvious until after the 
tenth or twelfth day of its exhibition ; but indeed 
we may safely affirm that little reliance is to be 
placed upon the influence of the most powerful 
antispasmodics, direct or indirect, in this disease. 

[The Cannabis Indica or Indian Hemp has 
been recommended, by Dr. O'Shaughnessy, of 
Calcutta, as an " anti-convulsive remedy" of the 
greatest value ; and when given boldly, and in 
large doses, as a successful remedy in traumatic 
tetanus. (Pereira, Elements of Mat. Med., 2d 
edit. p. 1096: Lond. 1842 ; and Dunglison's New 
Remedies, 4th edit. p. 133 : Philad., 1843.)] 



In chorea, when purgatives have failed to pro- 
cure relief, antispasmodics, such as musk, opium, 
and belladonna, have been freely administered ; 
but in this disease more decided benefit has been 
obtained from tonics operating as antispasmodics 
than from either narcotics or musk. Much ad- 
vantage has resulted from the use of the nitrate 
of silver, the carbonate of iron, and arsenious 
acid ; all of which operate as indirect antispas- 
modics. It is true, that, in some cases in which 
these tonics have failed, the disease has yielded to 
the use of musk and camphor ; but, in general, 
less advantage has been derived from the employ- 
ment of direct antispasmodics, than, from the 
nature of the disease, might have been reasonably 
anticipated. 

Antispasmodics effect little good in epilepsy. 
Some of the narcotics have sometimes appeared 
to prove useful ; but we have seen them all fre- 
quently fail in relieving this disease. Among the 
indirect antispasmodics, the preparations of zinc, 
copper, mercury, and arsenic, have ei.ch had a 
transitory reputation ; but if any of the metallic 
tonics merit confidence, it is the nitrate of silver, 
which operates by diminishing the susceptibility 
to those impressions that produce irregular action. 

In asthma, at least in one form of it, antispas- 
modics have been found highly beneficial. Assa- 
fcetida among the direct, and opium and stra- 
monium among the indirect antispasmodics, have 
been found capable of accomplishing every thing 
to be expected from this order of remedies in that 
affection. It is singular that in this country opium 
should not have been smoked, in the manner in 
which the Chinese employ it, for the relief of 
spasmodic asthma ; as the same circumstances 
which render stramonium serviceable when 
smoked are likely to render opium still more so ; 
and the experiment is worthy of being tried. In 
hooping-cough, the direct antispasmodics have 
been little employed ; but some of the indirect, 
for example, belladonna and conium, are much to 
be relied upon. Our experience in the use of the 
extract of belladonna enables us to offer the fol- 
lowing directions for its administration. Sup- 
posing a child of five years of age to be the ob- 
ject of hooping-cough, — after administering an 
emetic and purgative, a pill containing one-tenth 
of a grain of extract of belladonna may be given 
every fifth hour ; and the dose gradually increas- 
ed, until the sight be affected, and a scarlet efflo- 
rescence closely resembling the eruption of scar- 
latina appears on the skin. Whilst this state 
continues, the cough is often suspended ; and by 
maintaining it for some time, both the violence 
of the paroxysms is abated, and the continuance 
of the disease greatly shortened. The adjunct 
which we have found most beneficial is the hydro- 
cyanic acid, in doses of one minim, administered 
in any convenient vehicle ; but it should be gen- 
erally known that the efficacy of <he extract is 
destroyed by alkaline solutions.* 

In colic, the benefit to be expected from anti- 
spasmodics depends much upon the exciting causes 
of the attack. In simple constriction of the in- 
testines, narcotics will answer every indication 
intended to be fulfilled ; but when flatulence i» 

* A fart ascertained by Professor Runge. j?nn cfi 
Chimie, torn, zxvii. p. 32. 



126 



AORTA, (ANEU 



the exciting cause of the spasmodic constriction, 
assafoetida and the direct antispasmodics will be 
found serviceable ; and, when there is constipa- 
tion, calomel and aperients must be joined to the 
antispasmodics. Opium, in such cases, tends 
rather to augment than to impede the operation 
of purgatives, although the extract of hyoscyamus 
is frequently preferred. 

In no disease have antispasmodics more satis- 
fied the anticipations of the practitioner than in 
hysteria. [It is the only disease, in which, at the 
present day, direct antispasmodics are much used.] 
In this affection the convulsions are of the most 
severe description. During the paroxysm, the 
direct antispasmodics, especially assafoetida and 
valerian, have been found very useful, when pre- 
scribed in sufficient doses, which is rarely the 
case ; for, as we have already said, little benefit 
can be expected unless the doses be much larger 
than those usually prescribed. During the inter- 
vals, the metallic tonics should be chiefly relied 
upon as antispasmodics ; and, indeed, it is only 
by endeavouring to correct the morbid susceptibi- 
lity existing in these cases that any permanent 
benefit can be expected. 

Upon the whole, the range of the order of anti- 
spasmodics is extremely circumscribed ; at best, 
the different substances can he regarded as auxi- 
liaries only. Spasm is to be regarded rather as 
the result of causes which are to be removed, than 
as a circumstance for which remedies are to be 
directly administered. 

[It would seem, that all the direct — and such 
only can be esteemed true antispasmodics — must 
produce their effect by virtue of the new impres- 
sion which they make on the olfactory and gus- 
tatory, or on the gasiric nerves, or on both ; thus 
deriving from the inordinate action in some other 
part of the nervous system. All the direct anti- 
spasmodics aie, indeed, well calculated to effect 
this derivation. .Most of them, as assafoetida, 
castor, Dippel's oil, valerian, and skunk-cabbage, 
being exceedingly offensive, and at the same time 
possessed of excitant properties. In ordinary 
eases of spasm, not dependent upon an excited 
state of vessels, anything, therefore, that will pro- 
duce a new nervous impression may prove anti- 
spasmodic. Narcotics do so by blunting the 
impressibility of the nervous system ; nauseous 
agents produce their effects upon the olfactory or 
gustatory nerves ; and, if they be excitants at the 
same time, upon the nerves of the stomach. Cer- 
tain highly nervous and imaginative persons can 
feel pains wherever they please ; and many an 
individual, by the perusal of cases of disease, has 
fancied himself affected with the same sufferings 
which he has seen depicted. If, therefore, atten- 
tion can direct the nervous afflux to a part, it is 
obviously of great moment so to impress flie ner- 
vous system of the individual, that no concentra- 
tion of the kind may take place towards the suf- 
fering organ ; and this may be effected by engaging 
the mind, in light cases, on some subject of enter- 
tainment or reflection ; in stronger cases, by im- 
pressing the totality of the nervous system, as by 
narcotics; or by affecting nerves at a distance 
from those implicated, as by the direct antispas- 
modics more especially. (Dunglison's General 



RISM OF THE) 

T/urapeutics and Materia Medica, I 396: Philad 
18-13.)] A T. TtiOMSOX 

AORTA, aneurism of the. The aorta, in 

common with the other arteries of the body, is liable 
to ancurismal disease, the anatomical characters 
of which are comprehended under the four fol 
lowing varieties : — 

l st ._ Dilatation, which is an enlargement of 
the whole circumference of the. artery. 

2d. — True aneurism, which is a sacculated 
dilatation of a portion only of the circumference, 
or of one side of the artery. 

3d. — False aneurism, which is formed by 
ulceration or rupture of the internal and middle 
coats, and expansion of the external or cellular 
into a sac. It is called primitive, when all the 
coats are directly divided, as by a wound ; and 
consecutive, when it is consequent on ulceration 
or rupture of the internal and middle coats. 

4th. — Mixed aneurism, which is a superven- 
tion of false upon true aneurism, or upon dilata- 
tion ; that is, after dilatation, either partial or gen- 
eral, of all the three coats, the internal and middle 
burst, and the external alone expands into a fur- 
ther sac, surmounting the original dilatation or 
true aneurism. 

Formation and anatomical characters 
of the several species of aneurism. 

1st. Dilatation, or enlargement of the 
wliole circumference of tlie Aorta* — When 
the coats of the aorta, whether from inflammation 
or from any other morbid action, have become 
diseased, they lose their elasticity, a quality which 
resides principally in the middle tunic. As fluids 
press equally in every direction, the blood pro- 
pelled by each contraction of the heart into the 
aorta, exerts not only a longitudinal, but a lateral 
force, which expands the vessel, and constantly 
tends to enlarge its caliber. The elasticity of the 
arterial walls enables the vessel to resist this ex- 
pansive force, and to regain its previous caliber 
after the diastole. Consequently, when the elas- 
ticity is impaired or lost, the vessel, not being 
able to regain its original dimensions after each 
diastole, becomes permanently dilated ; and this 
takes place to a greater or less extent, and with 
greater or less promptitude, in direct proportion 
to the predominance of the distending over the 
resisting force. 

It very rarely happens that a dilated aorta does 
not present, in its interior, some of the morbid 
changes already described, (sec Arteritis); 
namely, cartilaginous, steatomatous, atheromat- 
ous, or calcareous depositions, with a thickened, 
wrinkled, and fragile state of the internal coat. 
When such depositions are not apparent, the 
walls, according to our observations, are always 
more or less indurated, opaque, and inelastic ; and 
are sometimes extenuated, particularly the middle 
coat, and sometimes thickened, with a softened 
and easily separable state of the internal coat : a 
condition of parts which is a much more natural 
cause of dilatation than paralysis of the middle 
coat, supposed by some authors to be its cause 
when no depositions were manifest. 

The ascending portion, and arch of the aorta, 
particularly the latter, are by far the most frequent 



AORTA, (ANEURISM OF THE) 



121 



Beats of dilatation ; but the descending portion, 
both in the chest and abdomen, is sometimes 
affected, and the dilatation is then either uniform 
throughout the whole length of the vessel, or it 
consists of one or even a series of ovoid or fusi- 
form expansions. The side of the artery adhe- 
rent to the spine, and the lesser curvature of the 
arch, yield less readily than the other parts. Dila- 
tation of the aorta does not, in general, exceed 
twice the natural caliber of the vessel, but we 
have occasionally seen it attain three, or even four 
times that size. When such is the case, it fre- 
quently presents many minor bulgings or pouches, 
which give it a considerable resemblance to the 
transverse arch of the colon. The walls of these 
pouches are often extenuated and semi-transparent 
from horn-like and calcareous depositions, and it 
is here more especially that mixed aneurism is 
apt to take place ; for the brittleness of deposi- 
tions causes rupture of the internal and middle 
coats, and the engraftment of false aneurism upon 
the true. 

Dilatation of the pulmonary artery is extremely 
rare. We have met with one remarkable case in 
which it was enlarged to four inches and a half 
in circumference. Dilatations, even though pouch- 
ed, scarcely ever contain laminated coagula ; for 
the surface is. in general, too smooth to arrest the 
blood. When they do take place, it is in conse- 
quence of an ulcerated or fissured state of the 
internal membrane, which forms nuclei for the 
adhesion of fibrine.* The coagula thus formed 
occasionally fdl up the whole of the dilated por- 
tion, and leave the canal of the artery of its 
natural caliber. 

The great arterial trunks rising at right angles 
from the aorta, as the innominata and coeliac, gen- 
erally participate in the dilatation : the left subcla- 
vian almost always remains exempt ; without 
doubt, says Laennec, on account of the acute an- 
gle at which it branches off. Dilatation takes 
place not only in the aorta and its immediate 
trunks, but sometimes in smaller and more remote 
arteries, as, for example, the carotid by the side of 
the sella turcica, the temporal f and emulgent} 
with their ramifications, the arteries of the extre- 
mities, and those feeding tumours of any descrip- 
tion, particularly fungus haematodes and the hae- 
morrhsigic na?vus or aneurism by anastomosis of 
John Bell. 

2d. True Aneurism, or lateral partial 
dilatation of tlie Aorta. — True aneurism dif- 
fers from dilatation in the circumstances, that it is 
an enlargement of a limited portion only of the 
circumference of the aorta ; that it generally rises 
with an abrupt margin ; and that its neck is, in 
most cases, narrower than the body of the sac. 
Its formation is to be attributed to a loss of elasti- 
city, and. consequently, of resistance, in the par- 
ticular part only that dilates ; and the proofs of its 
existence consist in the possibility of tracing the 
internal and middle coats of the artery throughout 
the whole extent of the expansion, and in the 
presence within the sac of those morbid appear- 

* Burns, on Diseases of the Heart, p. 20G. Berlin and 
Bouillnuil. Case wxvi. 

t Craveilhier Essai sor I'Anat. Patholog. Tans, 1815, 
t. ii. ii 

I journal de Medecine par MM. Comsart, Leroui, et 
Boyer, torn. vii. p. '.'jj. 



ances which are peculiar to the internal coats of 
arteries, such as calcareous, cartilaginous, and 
atheromatous depositions, with slight fissures, and 
small red spots. These proofs have, of late years, 
been so frequently verilied by dissection, that the 
reality of aneurism by dilatation of all the coats 
of an artery is no longer problematical. Almost 
all the aneurisms of the ascending portion and 
arch are originally of the true species, but the 
false is sometimes engrafted upon them. The 
tumour generally springs from the anterior or the 
lateral part of the vessel, while the posterior part 
is little, if at all implicated : it sometimes attains 
the magnitude of a mature foetal heart, § and gen- 
erally inclines to the right side of the chest. 
When it springs from the root of the aorta, and 
the middle and internal coats happen to burst, 
there results, not a false aneurism surrounding the 
true, as in other parts, but a fatal extravasation 
into the pericardium. The reason of this is, that 
the part of the aorta referred to is destitute of the 
cellular tunic, and the pericardium which supplies 
its place, not being equally extensible, bursts, ra- 
ther than dilates into a false aneurism. In the 
same way the deficiency of the cellular coat in the 
arteries of the brain causes their rupture to be fol- 
lowed by an apoplectic extravasation, instead of 
by the formation of an aneurismal sac. It has 
been stated by a recent writer that a preparation 
in Mr. Hunter's collection subverts the doctrine 
that false aneurism does not form at the root of 
the aorta. The preparation of which he speaks, 
however, is not one of false aneurism, as the mid- 
dle coat is perfect, the internal one alone being 
diseased, or removed, (it is doubtful which,) at 
the base of the sac. It has not been denied by 
authors that true aneurism may form at the root 
of the aorta. We have ourselves seen it in more 
than one instance. Coagula are occasionally, but 
not often, found in true aneurisms ; they are usually 
in masses, adherent by a peduncle, and seldom in 
layers investing the walls unless the aneurism is 
very large ; the reason of which is, that the mouth 
of the sac being in general spacious, the blood 
has a sufficiently free ingress and egress to circu- 
late with force, while the surface of the sac is so 
smooth as not to arrest the fibrine, and cause its 
deposition in layers. But when the circulation is 
by any cause enfeebled, the blood stagnates and 
forms coagula in masses, which become adherent 
by limited portions or peduncles. True aneurism 
is much more rare than either false aneurism or 
dilatation. 

3d. False Aneurism, or Aneurism by ul- 
ceration of the internal or middle Coats. 

Nichols proved, by experiments made before the 

Royal Society of London, that, when the internal 
and middle coats of an artery are divided, and 
water or air is forced into the vessel, the external 
coat distends so as to form a small sac, (Philos. 
Trans, vol. xxxv. p. 443.) In the same manner, 
when the internal and middle coats are perforated 
by ulceration or a fissure, the blood, by its lateral 
pressure, gradually' raises the external coat, and 
expands it into a sac, which communicates with 
the interior of the artery, whose caliber is not er»- 



§ Corvisart. Journal de Medecine, par MM. Oorvisirt 
Leroux, et Boyer, t. vii. p. 3o5. Laenneo «le I'Ausruii 
t. ii. p. 091. 



128 



AORTA, (ANEURISM OF THE) 



larged, by a narrow aperture or neck. As the dis- 
tention proceeds, the externa] coat itself gives way, 
and the sheath of the vessel next opposes the effu- 
sion of blood ; finally, when this also yields, the 
contiguous parts, whatever be their texture, con- 
tribute to the formation of the sac, they having 
previously undergone thickening and agglutina- 
tion by chronic adhesive inflammation, to which 
distension had given rise. Such is the manner 
in which the sac is formed in aneurism from ulce- 
ration of the arterial coats. It presents no vestige 
of the middle or fibrous coat, nor the depositions 
connected with the internal membrane ; but its 
inner surface is extremely rugged and unequal 
from lymph irregularly deposited by inflammation. 
To this rugged surface adhere the layers of fibrine 
subsequently deposited by the blood. 

Perforation of the internal and middle coats is 
not always followed by aneurism of the kind de- 
scribed. Laennec met with a case in which the 
internal and middle coat had been divided by a 
narrow transverse fissure extending over two- 
thirds of the circumference of the artery ; and the 
blood, instead of distending the external coat into 
a sac, had insinuated itself between it and the 
fibrous, and dissected them from each other over 
upwards of half the circumference of the artery, 
from the arch of the aorta to the common iliacs, 
(De l'Auscult. torn. ii. p. 700.) Fissures of the 
kind described result from cracks or lacerations 
occasioned by calcareous depositions ; but the case 
of Laennec, and two similar cases mentioned by 
Mr. Guthrie, (Guthrie on the Diseases of Arte- 
ries, p. 40 and p. 43,) are the only instances within 
our knowledge in which a fissure has been follow- 
ed by more than a circumscribed effusion of blood 
around it, occasioning a slight swelling of the 
external coat. Nichols found this in the body of 
George II., (Philos. Trans, vol. lii. p. 269 ;) and 
Hodgson once met with it, (On Diseases of Arte- 
ries, p. 63.) 

The late Mr. Shekelton has described, in the 
Dublin Hospital Reports, vol. hi., another and 
previously unnoticed kind of aneurism; namely, 
the blood had forced its way through the internal 
and middle coats, dissected the. middle from the 
external or cellular for the space of four inches, 
and then burst again through the internal and 
middle coats into the canal of the artery ; thus 
forming a new channel, which eventually super- 
seded the old one ; the latter having become oblit- 
erated by the pressure of the tumour. 

[The term Dissecting Aneurism was given 
by Laennec to this form. Many such cases are 
now on record. Dr. Pennock (Amer. edit, of 
Hope on Diseases of the Heart, p. 408, Philad. 
1842,) refers to four that have occurred in the 
observation of American pathologists. In all these, 
the lesion was identical ; — the separation of the 
lamina? of the middle coat, by blood driven by the 
propulsive force of the heart through a rent caused 
by a laceration of the serous coat, and a partial 
.upture of the layers of the middle coat. From 
the examination of these pathological specimens, 
and from the fact that the attachment of the ex- 
ternal fibres of the middle coat to the cellular is 
much firmer than that of the layers of the middle 
coat between themselves, Dr. Pennock is induced 
r- 1 . believe that dissecting aneurism, when it occurs 



to any extent, will be found to be between the. 
lamina of the middle coat, and not between the 
middle and the outer coats o\' the artery. An 
excellent paper by Mr. Peacock on this form of 
aneurism is contained in the Edinburgh Medical 
and Surgical Journal for Oct. 1843.)] 

The causes of perforation of the internal and 
middle coats, and the formation of false aneurism, 
are, — 1. ulceration, generally occasioned by the 
detachment of calcareous incrustations, by athero- 
matous depositions under the internal membrane, 
and, more rarely, by tubercles, or small abscesses 
in the substance of the fibrous tunic : 2. rupture, 
or cracking, which takes place when the tunics 
have been deprived of their elasticity by cartila- 
ginous, steatomatous, fungous, and calcareous de- 
generation.* The immediate or exciting cause of 
the rupture is generally some violent exertion oi 
accident ; and in most instances patients with 
aneurism date it from some occurrence of this 
kind. Rupture does not appear ever to take place 
in a perfectly sound artery ; and if it did, the ex- 
periments of Dr. Jones prove that it would not be 
followed by an aneurism, as an effusion of lymph 
takes place, which strengthens the vessel in the 
lacerated part, (Jones on Hemorrhage, p. 125.) 

While aneurism of the ascending aorta and 
arch are, in the first instance, almost invariably 
true, though they occasionally become mixed, 
those of the descending aorta are generally false ; 
and the caliber of the artery is, with few excep- 
tions, not in the slightest degree dilated opposite 
to the tumour. Aneurism by perforation of the 
internal and middle tunics is the only species of 
which Scarpa admits the reality ; but the inaccu- 
racy of his opinions has been fully proved, and, 
as before stated, there is no longer any question 
respecting the actual existence of aneurism bv 
dilatation of all the coats. The cases of false aneu- 
rism that are on record are very numerous. Re- 
ference may be made to the works of Lancisi, 
Morgagni, Guattoni, Scarpa, Desault, Warner, 
Hodgson, Home, Laennec, Bertin, and Bouil- 
laud. 

4. Mixed Aneurism, or false Aneurism 
surmounting true. — This species is formed in 
the following manner. All the three tunics of 
the artery first undergo an expansion, which, ac- 
cording to its form, constitutes either a dilatation 
or a true aneurism : as the expansion proceeds, 
the internal and middle tunics burst, and the ex- 
ternal, being more extensible, dilates into a sac, 
surmounting the original enlargement. Aneurisms 
of this description are very numerous. Whether 
the cyst succeeding a perforation of the arterial 
walls has been preceded or not by their dilatation ; 
in other words, whether the aneurism is true or 
mixed, it communicates with the cavity of the aorta 
by an aperture more contracted than its body, and 
circumscribed by a prominent border, correspond- 
ing with a kind of strangulation. This disposi- 
tion of parts has been perfectly described by Scar- 
pa, and admirably represented in his plates. 

GjBNEKAL OliSEUVATIONS OX ANEURISMS OF 
THE AOIITA. 

Haller and MM. Dubois and Dupuytren have 
remarked a variety of aneurism, in which the 



* Scarpa on Aneurism, §20,21, 22. 
cult. loin. ii. p. 704. Hodgson, p, 62. 



Laennec de l'Aus- 



AORTA, (ANEURISM OF THE) 



129 



internal membrane makes a hernia through the 
ruptured fibrous coat, and lines the sac, which is 
formed by the external or cellular coat. Hernia 
of the internal membrane may occur, according 
to Laennec, in very small aneurisms : he had seen 
it in two, which were not larger than cherries; 
but when the tumour increases, the internal mem- 
brane speedily bursts. This he found to have 
been the case in two other aneurisms which did 
not exceed the size of walnuts, (Dc l'Auscult. torn, 
ii. p. 693.) The experiments of Mr. Hunter, 
Scarpa, and Sir E. Home prove, that when the 
external and middle coats of an artery are remov- 
ed, the internal one does not dilate into an aneu- 
rism, but either bursts, or is strengthened by gra- 
nulations arising from its surface, and by adhesions 
formed with the surrounding parts. 

Corvisart having found several firm, solid tu- 
mours, of the size of nuts, intimately adherent to 
the aorta, while the external and middle coats ap- 
peared to be deficient at the point of attachment, 
was led to imagine that extraneous tumours, for 
such he conceived them to be, becoming adherent 
to arteries, led to the formation of aneurism, (Essai 
sur les Maladies du Coeur, p. 313.) Hodgson, on 
the contrary, regards the tumours in question as 
instances of aneurism cured, the sac having been 
filled up by lamellated coagula, (On Diseases of 
Arteries, p. 127,) and the volume of the tumour 
diminished by absorption ; and Laennec, Bertin, 
and the best authorities subscribe to his opinion. 

As an aneurismal sac enlarges, the surrounding 
parts become involved in its composition. Thus 
the bones, muscles, and various other structures, 
often contribute to its formation. The viscera, 
also, become implicated when the tumour is situ- 
ated in their vicinity ; and the membranes with 
which they are invested being distended to their 
utmost, finally yield, and the sac bursts into their 
cavities. Accordingly, aneurisms frequently prove 
fatal by discharging their contents into the lungs, 
oesophagus, stomach, intestines, bladder, &c. The 
size which the tumour attains depends upon the 
nature of the surrounding parts, and is very much 
determined by their extensibility — a property 
which is almost in direct proportion to the quan- 
tity of cellular tissue of which they are composed. 
Hence it is that, when the disease is situated at 
the root of the aorta, where the pericardium sup- 
plies the place of the more extensible cellular coat 
of the vessel, the sac bursts into the pericardium 
before it has attained any great magnitude. Hence, 
also, it is that, in the cranium, where the arteries 
arc destitute of the cellular coat, and are ill support- 
ed by the pia mater and the soft pulpy substance 
of the brain, aneurism is extremely rare ; for such 
a lesion of the coats of the arteries as would else- 
where give rise to aneurism, is here attended with 
rupture and apoplectic effusion. It has been al- 
ready stated, however, that the arteries of the 
brain are not insusceptible of dilatation. 

One of the first circumstances that almost inva- 
variably follows the formation of true aneurism is, 
the deposition of the librine of the blood upon the 
internal surface of the sac. This deposition takes 
place in successive concentric layers, which have 
a different aspect according to the date of their 
formation. The most, central consist simply of 
blood more or less firmly coagulated, and they are 

Vol. I 17 



probably formed subsequent to death ; a little far- 
ther the coagulum is drier, paler, and evidently 
composed of a large proportion of fibrine : still 
farther are layers of pure, whitish, yellowish, or 
greyish fibrine ; and, finally, in contact with the 
walls of the cyst, are layers of the same matter, 
hut completely opaque, of a somewhat friable con- 
sistence, like dryish paste, and very closely re- 
sembling flesh which has been deprived of its 
colour by boiling. The most recent layers adhere 
to each other so slightly as almost to float within 
the sac; those beneath are united by a flossy or 
nappy cellular tissue, the adhesion being stronger 
in proportion as the layers are older. Patches of 
vivid red, formed by reticulated blood-vessels, are 
occasionally found in the fibrine, and blood often 
penetrates between its layers, and stains those 
which are friable, or decomposed. Coagula are 
softer in some cases than in others, though the 
physical circumstances be the same in both. The 
difference is probably owing to a difference in the 
chemical qualities of the blood. From these ana- 
tomical characters it is evident that lamellated 
coagula form by the successive depositions of the 
fibrine of the blood ; and the depositions are ac- 
counted for by the stagnation of the blood within 
the sac ; for it is proved, by experiment and ob- 
servation, that coagulation of this liquid takes place 
whenever its course is interrupted ; hence the 
polypi that are found in the heart, the great veins, 
and the arteries, when the circulation through 
those parts is obstructed. The coagulation of 
blood within a false aneurism is favoured by two 
circumstances, the narrowness of the aperture of 
communication with the artery, and the rugged- 
ness of the interior of the sac. In true aneurism, 
as has already been stated, the width of the aper- 
ture of communication, and the smoothness of 
the interior of the sac are unfavourable to the 
coagulation, and accordingly fibrinous layers are 
very seldom found in those aneurisms, unless they 
are of great size, although they often contain co- 
agula in masses attached at one part only by a 
peduncle of greater or less thickness. The thick- 
ness of fibrinous depositions within aneurisms is 
sometimes very great. Most commonly it is from 
half an inch to an inch and a half, but we have 
seen it exceed three inches : it is generally greater 
on one side of the sac than another. Laennec 
has seen fibrinous coagula as compact and dia- 
phanous as horn softened to the utmost by heat, 
and of a thickness exceeding five inches' breadth. 

Aneurisms, and the diseases of the coats of 
arteries which precede their formation, are much 
more frequent in men than in women. Of sixty- 
three cases seen by Hodgson, fifty-six occurred in 
the former, and only seven in the latter. (On 
Diseases of Arteries, p. 87.) We have found the 
proportion rather larger in females with respect 
to aneurism of the aorta, but with respect to ex- 
ternal aneurism it is much smaller, perhaps not 
exceeding one in fifteen to twenty. 

[In the winter of 1843-4, Dr. Dunglison had an 
opportunity of exhibiting to the clinical class of 
the Philadelphia Hospital the morbid appearances 
presented in three cases of internal aneurism .- 

two of the aorta, and one of the internal diacs 

which occurred in the wards under his charge 
The subjects were all females.] 



130 



AORTA, (ANEURISM OF THE) 



Effects of ANEURISMS of thj; aorta on TBI 

CONTIGUOUS PAHTS. 

The effect of aneurisms of the aorta on the con- 
tiguous parts vary according to the volume, the 
form, and the position of the tumour. Dilatation, 
when not very considerable, produces little de- 
rangement of the surrounding parts ; for as the 
swelling is equable and diffuse, it does not exert 
a pressure on any one organ in particular, and its 
magnitude is not such as to create much inconve- 
nience from general infarction. The worst of its 
effects are those which it produces on the trachea 
and great bronchi ; for though the pressure be 
slight, it often suffices, in consequence of the great 
irritability of these parts, to occasion considerable 
dyspnoea. It must not, however, be imagined that 
dilatation is an unimportant affection : it will 
hereafter be shown that, when complicated with 
enlargement of the heart, which it generally brings 
on, it is one of the most formidable diseases inci- 
dent to the circulatory apparatus. 

An aneurism which forms a defined tumour, 
whether it be of the true or the false species, and 
whether it be large or small, may produce the 
most pernicious effects. These are, — 

1st. Such as result from compression of the 
neighbouring parts. 

2d. Such as result from their destruction. 

1st. By compression, the functions of the lungs, 
bronchi, heart, and oesophagus, are deranged, and 
that sometimes to a fatal extent. In the abdo- 
men the functional derangements are compara- 
tively inconsiderable, and very rarely endanger 
life. The reason of this is twofold, — first, that 
the abdominal organs are not of so vital a nature 
as the thoracic; and secondly, that the tumour, 
instead of being pent up in a rigid bony case like 
the chest, is permitted, by the yielding of the in- 
testines, and the distensibility of the abdominal 
parietes, to expand freely in almost ever)" direc- 
tion. Pressure on any particular organ, therefore, 
is in a great measure obviated by the want of 
counter-pressure — of a fulcrum. Ventral aneurism, 
however, sometimes deranges the respiration by 
preventing the due descent of the diaphragm ; an 
effect which may proceed either from the magni- 
tude alone of the tumour, or, what is much more 
common, from its being seated near or in the sub- 
stance of the muscle, and impeding its motions. 
Ventral aneurism is also occasionally character- 
terized by involuntary evacuation of the urine and 
faeces, by remarkable alternations of constipation 
and diarrhoea, and by deep-seated excruciating 
pains, resembling those of lumbar abscess. These 
symptoms arise from compression of the nerves, 
particularly the hypogastric plexus around the 
aorta. 

2d. The consequences of destruction of conti- 
guous parts are far more formidable than those 
resulting from compression. When the tumour 
exerts an unusual pressure on any organ or tex- 
ture, adhesive inflammation takes place and unites 
the paits in contact. As the pressure increases, 
absorption and ultimately perforation of the sac 
ensue, and death from internal hemorrhage is the 
immediate consequence. The perforation takes 
place either by sloughing, or by laceration, ac- 
cording to the nature of the membrane or texture 
perforated. Thus, when the tumour advances to 



the akin, or when it extends into a cavity lined 
by a mucous membrane, it bursts by the separa- 
tion of a slough which has formed upon its most 
distended parts, and not by laceration. On the 
contrary, when the sac projects into a cavity lined 
by a serous membrane, sloughing of the mem- 
brane does not take place, but the parietes of the 
tumour, having become extremely thin in conse- 
quence of distension, at length burst by a crack 
or fissure, through which the blood is discharged. 
An aneurism may burst into a great variety of 
parts, which we shall notice in succession. 

When the. lungs are in contact with the tu- 
mour, adhesion, absorption of the sac, and rupture 
of the pleura take place, and the effused blood 
deluges the bronchi and causes suffocation. It 
often happens that an aneurism of the ascending 
aorta, or arch, compressing the trachea, or one of 
the great bronchial trunks, opens its way into it 
by ulceration of the cartilaginous rings and slough- 
in - of the mucous membrane, and causes suddenly 
fatal haemoptysis. More rarely, perforation takes 
place into the oesophagus, and death then ensues 
from hoematemesis. Aneurisms occasionally burst 
at the origin of the aorta, and cause death by 
effusion of blood into the pericardium. The fatal 
event, however, is not always so sudden as in the 
preceding cases ; a circumstance which Laennec 
attributes to the pericardium being supported, and 
the effusion, consequently, restrained, by the ge- 
neral infarction of the chest, occasioned by the 
presence of the tumour. This reason appears to 
us unsatisfactory, because, as before explained, 
aneurisms at the root of the aorta generally burst 
before they attain any considerable magnitude: 
nor, if large, would the resistance offered by the 
atmospheric pressure in the lungs, equal the force 
with which the blood tends to escape into the 
pericardium — a force equal to the propulsive 
power of the left ventricle. It is, perhaps, more 
probable that the inextcnsibility of the pericardium 
beyond a certain point, and the resistance of the 
heart to compression, form the principal powers 
which limit the effusion of blood. It would ap- 
pear that life is sometimes protracted for a consi- 
derable period after the rupture of the sac ; for ir. 
specimens presented to the Societe de la Faculte 
de Medecine by M. Marjolin, the margins of the 
aperture, according to Laennec, were polished, as 
if of old standing, and, as it were, fistulous. 
(Laennec, Opt. Cit. ii. p. 715.) Rupture into 
the pericardium is very rare. Laennec never met 
with an instance. The first that has fallen under 
our own observation occurred recently at St. 
George's Hospital. Morgagni (Epist. xxvi. Nos. 
7, 17, 21) and Scarpa, (On aneurism, § xix. p. 
103, et sequent,) however, have collected together 
a considerable number of these cases, and Hodg- 
son saw two, in which the aneurism, beginning 
half an inch above the semilunar valves, occupied 
the whole ascending aorta and arch. 

Aneurisms have been known, but very rarely, 
to burst into the pulmonary artery. MM. Pajen 
and Zeink saw an instance, (Bulletin de la Fa- 
culte de Medecine, 1819, No. 3,) and Dr. Wells 
another.* Professor Monro, tertius, showed us a 
preparation of an ancurismal pouch springing 

* Tr.-ins. of a Society for the Improvement of Med. 
Chirurg. Knowledge, vol. iii. u to. 



AORTA, (ANEURISM OF THE) 



131 



from the aorta, directly against the pulmonary 
artery ; and it is probable that, if the patient's life 
had been prolonged, ruptiwe would have taken 
place into the artery. The left cavity of the 
pleura and the posterior mediastinum are the parts 
into which thoracic aneurisms most frequently 
burst It is extremely seldom, on the contrary, 
that they open into the right pleura. Laennec has 
seen an aneurism of the descending aorta, which 
had compressed and destroyed the thoracic duct, 
and produced engorgement of all the lacteal ves- 
sels. Aneurisms sometimes compress the de- 
scending vena cava, and cause cerebral conges- 
tion, oedematous intumescence of the face, and 
even apoplexy. We have met with several in- 
stances of this kind. Corvisart,* and Bertin and 
Bouillaud, (Traite des Maladies du Cocur, p. 137,) 
each cite a case of apoplexy thus occasioned. 

Another effect of aneurisms is to obliterate ar- 
teries springing from or contiguous to them. We 
have met with two cases in which both the left 
carotid and subclavian were plugged up at their 
origin from the tumour. The obliteration is some- 
times effected, not by a plug of lymph, but by 
contortion or compression of the vessel. Mere 
contraction of the origin of arteries from these 
causes is very common. Ventral aneurisms may 
open their way into the various abdominal vis- 
cera, as the intestines, the bladder, &c. 

Aneurisms not only cause destruction of the soft 
parts, but, what is still more remarkable, erosion 
of the bones. This phenomenon has been variously 
explained. The old pathologists erroneously 
ascribed it to a chemical solvent power of the 
blood. Hunter, Scarpa, and Hodgson, thought 
that it resulted from absorption of the earthy mat- 
ter, in consequence of the pressure of the sac. 
Corvisart and Laennec attribute it to a sort of de- 
trition or wearing down, produced by a purely 
mechanical action. Bertin and Bouillaud believe 
that it is more or less dependent on inflammation. 
To us it appears that absorption and mechanical 
detrition are the principal agents concerned in 
producing the effect. That pressure is capable of 
exciting absorption of bone is certain, as the ver- 
tebra; have been found excavated by an aneurismal 
tumour, without being divested of their perioste- 
um (Hodgson, p. 79.) ; and there can scarcely be 
a doubt, that, when a denuded bone is exposed to 
the constant dashing of a column of blood, it un- 
dergoes disintegration by the mechanical detach- 
ment of its particles. Whether inflammation ever 
contributes to the effect, is difficult positively to 
determine. Appearances, however, are adverse to 
this opinion, as pus has never been found on bone 
eroded by an aneurism ; as exfoliation scarcely 
ever takes place ; and as nothing is discovered on 
it analogous to the cicatrization or irregular repro- 
duction which is observable in other bones when 
affected with caries. Cartilage, whether exposed 
to the action of the blood in aneurismal sacs, or 
to the pressure alone of the tumour, either remains 
entirely uninjured, or suffers incomparably less 
than hone. This is most manifest in the inter- 
vertebral substance, and the cartilages of the false 
ribs. The circumstance is attributable to the 
elasticity of cartilage, which protects it from me- 

* Journal de Medeeine, par MM. Corvisart, Lerouz, 
el Boyer, torn. xii. p. 159. 



chanical disintegration, and to its almost inorganic 
structure, which renders it little susceptible of ab- 
sorption or ulceration. The bones liable from 
their position to be eroded by aneurism, are the 
vertebra?, the sternum, the ribs, and sometimes the 
ossa ilii. 

It is principally by aneurisms of the descending 
aorta that the vertebra? are injured. In these 
cases the portion of the sac in contact with the 
vertebra? is entirely destroyed, and its borders 
adhere very firmly around the eroded part of the 
bone, on which the blood plays freely in conse- 
quence of the fibrinous layers having been ab- 
sorbed at that part. The destruction is sometimes 
so deep that the shell of the vertebra? forms the 
only partition between the sac and the spinal 
canal. Very rarely, however, does rupture take 
place into the canal. We are not aware that 
there are more than two instances on record, one 
by Laennec in the Revue Medicale for 1835, and 
another of which the preparation, by Mr. Chandler, 
is in the Hunterian Museum. 

Ventral aneurisms seldom produce erosion of 
the bones ; because the abdominal viscera and 
walls yield to the tumour. 

It is by aneurisms of the ascending aorta that 
the sternum and ribs are eroded, and the tumour 
generally presents on the right side. Aneurisms 
of the arch and the innominata project at the 
upper part of the sternum, and about the clavicles, 
which they have been known to dislocate at their 
sternal extremities. When the tumour is con- 
nected with the posterior part of the arch, it shows 
itself underneath the left clavicle. According to 
Hodgson, when the periosteum contributes to the 
formation of the sac, its vessels continue to secrete 
an earthy matter, which, in some instances, has 
been deposited to such an extent as to form a 
considerable portion of the tumour. 

Small aneurisms have the effect of destroying 
the bones in a greater degree than large ; a cir- 
cumstance attributable to the greater concentration 
of the pressure exercised by them. 

Signs and diagnosis of aseuhisms of the 

AORTA. 

The signs of aneurism of the aorta are of two 
classes. 

1. General signs. 

2. Signs afforded by auscultation, percussion, 
&c. 

These two classes of signs will first be described 
separately, and a brief summary then given of the 
signs of the two classes conjointly, which refer to 
the several forms of aneurism. 

I. General signs of aneurism of the 
aorta. 

When an aneurism is buried deep in the chest, 
and not capable of being detected by the sight and 
touch, it does not present a single general sign 
which is peculiar to itself, and, therefore, pathog- 
nomonic of its existence. There are even cases in 
which it occasions no functional derangement — no 
inconvenience whatever ; and the first circuin 
stance that unveils the truth is, the sudden death 
of the patient while apparently in the enjoyment 
of perfect health. We have met with six or seven 
instances in which large aneurisms had existed 
without awakening even a suspicion in the mind 
of the medical attendant. One, in particular, 



132 



AORTA, (ANEURISM OF THE) 



eluded the penetration of a distinguished foreign 
auscultator, though he explored the lungs with 
eminent success. We are acquainted with only 

one general sign of aneurism of the thoracic aorta 
which is unequivocal and certain, namely, a tumour 
presenting externally, and offering an expansive 
as well as heaving pulsation, synchronous with 
the action of the heart. Of the remaining general 
signs, a large class are identical with those of 
organic disease of the heart, viz. palpitation, dys- 
pnoea, cough, tendency to syncope, terrific dreams, 
starting from sleep, haemoptysis, livid or otherwise 
discoloured complexion, cerebral or hepatic con- 
gestions, serous infiltration, &c. This identity 
arises from an identity of cause ; namely, an ob- 
stacle to the circulation, which depends either 
upon the aneurism alone, or conjointly upon it 
and a disease of the heart, to which, sooner or 
later, the aneurism almost invariably gives birth. 
It is obvious, therefore, that the signs of this class 
are equivocal. There are, however, certain other 
general signs which are more characteristic : yet 
even these are of themselves ambiguous and un- 
satisfactory ; as they only bespeak lesions of the 
viscera, or derangement of their functions, but do 
not proclaim the latent cause of the mischief. But 
when they coincide with the signs derived from 
auscultation, they lose their ambiguity, and rise 
into real importance; for the two classes of signs, 
general and stethoscopic, are a commentary on 
each other, and reciprocally borrow a precision 
and certainty of which they are individually desti- 
tute. We shall succinctly describe the general 
signs to which we refer, and subjoin to each the 
principal sources of fallacy. The means of detect- 
ing the latter we shall point out in the final 
summary. 

1. When the tumour has attained a conside- 
rable magnitude, the cavity of the chest is preter- 
naturally crowded, and the patient complains of a 
sense of constriction, infarction, and oppression. 
But these sensations are common to almost all 
diseases of the chest. 

2. The radial pulses are sometimes dissimilar, 
or one is extinct ; an effect dependent on obstruc- 
tion or obliteration of the arteria innominata, or 
left subclavian. But the difference of the two 
pulses at the wrist may proceed from a variety 
of causes independent of aneurism of the aorta, as, 
contraction of the origin of either subclavian from 
osseous, cartilaginous, steatomatous, or other depo- 
sition ; obstructions in the course of the artery, 
occasioned by tumours, wounds, subclavian aneu- 
rism, &c. ; an irregular subdivision of the hume- 
ral, brachial, or radial artery. We have known 
the most ludicrous surmises occasioned by the 
radial crossing to the outside at the middle of the 
fore-arm, and the superficialis volffi supplying its 
place at the wrist. 

3. When the origin of either subclavian is con- 
tracted, the pulse at the corresponding wrist is a 
little later than the ventricular systole. We have 
not found this symptom uniformly present. The 
heart is more frequently its source than the aorta, 
and we have observed it to be most considerable 
in cases of regurgitation into the left auricle ; but 
obstruction of the aortic valves may occasion it in 
* minor degree, particularly if this lesion is accom- 
panied with extenuation or atony of the ventricu- 



lar parieles. When the sign exists in both pulses, 
the presumption is strong that its source is in the 
heart. 

4. According to Corvisart, a purring tremor — 
the frimissement cataire o( Laennec — is some 
times perceptible to the hand at the middle oi 
upper part of the sternum, and indicates aneurism 
of the ascending aorta. Purring tremor, above the 
clavicles, is an almost constant concomitant, and 
therefore a valuable sign, of dilatation of the arch ; 
but, according to our experience, it is unfrequently 
and imperfectly occasioned by sacculated aneu- 
risms, especially if lined by strata of lymph. We 
have never known the tremor to be occasioned 
below the clavicles by dilatation, unless the en- 
largemcnt was so great as to extend beyond the 
lateral margins of the sternum, and allow the 
tremor to be felt through the intercostal spaces : 
but we have met with one case in which a dilata- 
tion of the pulmonary artery, though not volumi- 
nous, afforded a marked tremor between the carti- 
lages of the second and third ribs on the left side : 
this, however, is not remarkable, as the artery 
naturally lies nearly opposite to the part described. 
We have never known a sacculated aneurism 
create a tremor below the clavicles, unless the 
tumour had eroded the bones of the chest, and 
presented externally underneath the integuments. 

But the purring tremor may be occasioned in 
any part of the chest by mucous rattles, particu- 
larly those of the snoring kind, in the large bron- 
chial tubes ; and we have observed that, when 
derived from this source, it is a very common 
cause of deception, in reference both to aneurisms 
of the aorta and ossifications of the heart. Purring 
tremor of the pulse is regarded as a sign, though 
it is a fallacious one, of ossification of the aortic 
valves. From many dissections, it has appeared 
to us to be generally connected with two circum- 
stances, viz. a powerful action of the heart, and 
ruggedness, without appreciable obstruction, of 
the aortic orifice, or interior of the vessel. It, 
therefore, seldom exists, unless cither the action 
of the heart be accelerated, or the left ventricle be 
hypertrophous. 

5. When the trachea, or primary bronchial 
divisions, are compressed by an aneurismal tumour, 
a harsh wheezing, or sibilous sound, proceeding 
deep from the throat, characterizes the respiration; 
the voice is either croaking or reduced to a whis- 
per, or it is a compound of both ; the breathing is 
often extremely laborious, and when the heart is 
simultaneously diseased, dyspnoea sometimes oc- 
curs in paroxysms of the most suffocating severity. 
When the oesophagus is compressed, deglutition 
of solids is rendered difficult, and sometimes im- 
practicable ; for the descent of the morsel excites 
an excruciating pain from the summit of the 
sternum to the spine, or lancinating deeply in 
every direction through the chest. 

But compression of the trachea, or oesophagus, 
with the above symptoms, may be occasioned by 
tumours of any description. Wheezing respira- 
tion may proceed from an accumulation of gluti- 
nous mucus in the great branches. We have 
likewise known it produced in an extreme decree 
by laryngitis with thickening of the soft parts 
covering the arytenoid cartilages, ami also by 
ossification and ulceration of the larynx from 



AORTa, (ANEURISM OF THE) 



]33 



strumous, syphilitic, and mercurial disease. So 
difficult is it to distinguish the scat of wheezing 
respiration, that it has in many instances been 
imputed to an affection of the larynx, when it was 
in reality occasioned by an aneurism of the 
aorta; and bronchotomy has several times been 
actually performed with the view of obviating 
suffocation; 

G. When the vertebra? are eroded, the patient 
suffers an intense terebrating pain in the spine ; 
and when the brachial plexus of nerves is com- 
pressed by the tumour, an aching sensation per- 
vades the left shoulder, neck, scapula, and arm, 
with numbness, formication, and impaired motive 
power of the limb. But I have met with cases in 
which nearly similar pains were experienced, 
although there was no destruction of the verte- 
bra : and it is common to hear individuals affected 
with rheumatism or spinal diseases make the same 
complaints. The affection of the arm may be 
occasioned by various forms of organic disease of 
the heart, and it thus constitutes a part of that 
concatenation of symptoms which are denominated 
angina pectoris. We have likewise often met with 
it in hysterical females subject to palpitation, and 
occasionally in cases of pericarditis. In all these 
cases the pain probably originates in irritation of 
the cardiac plexus of the sympathetic, propagated 
to the brachial plexus. 

?. When, in consequence of an adhesion be- 
tween the aneurismal sac and the pleura, the blood 
plays upon the lungs, a sense of ebullition is said 
to be experienced. But the same symptom is 
familiar to individuals labouring under phthisis, or 
chronic mucous catarrh ; and it proceeds from the 
successive bursting of large bubbles, formed by 
the transmission of air through the fluid in tuber- 
culous caverns, or in the greater bronchial ramifi- 
cations. 

8. It occasionally happens that the patient suf- 
fers excruciating pain from a spasm, pursuing the 
course of the diaphragm, and binding the chest 
around, as with a cord. This symptom is too 
vague to be important, and it also occurs in hys- 
teria, gastrodynia, colic, spinal diseases, and rheu- 
matism of the diaphragm. 

9. A pulsation is felt underneath the sternum, 
or ribs, at the superior part of the chest. This, 
although one of the least equivocal signs of aneu- 
rism, is not without ambiguity. It may be occa- 
sioned by a tumour of any description, as an en- 
larged gland, or a cancer, interposed between the 
sternum and the aorta, and receiving the pulsation 
of the latter. Even Dr. Baillie says, " But we 
arc not to conclude from this symptom (viz., pul- 
sation at the superior part of the chest) that there 
is certainly an aneurism. I have felt the same 
kind of pulsation in other cases ; as, for instance, 
where the pericardium was found strongly to ad- 
here to the heart ; where there was a slight in- 
flammation upon the surface of the heart, with a 
little more water than usual in the pericardium ; 
and where a morbid enlargement had taken place 
in the heart, without any aneurismal swelling." 
Every one much conversant with disease must 
have made the same observations. 

10. A pulsation is felt above the sternum or 
clavicles. But this may be occasioned, 1st. by 
enlarged glands or other tumours seated on the 



subclavian artery, and receiving its pulsation ; 2d. 
by varix of the jugular vein at its junction with 
the subclavian ; both of which conditions have 
deceived expert practitioners ; 3d. by subclavian 
aneurism. This affection sometimes resembles 
aneurism of the aorta so exactly, that it is ex- 
tremely difficult to distinguish them. Allan Burns 
records a case in which all the eminent surgeons 
of the district were unanimous in pronouncing the 
affection subclavian aneurism, yet it proved to be 
aortic. (Surg. Anat. of Head and Keck, p. 30.) 
Sir Astley Cooper has published a number of simi- 
lar cases, and one is mentioned by Professor Monro 
tertius. (Elements of Anat. vol. ii. p. 249.) 4th. 
A pulsation above the sternum or clavicles may be 
occasioned by carotid aneurism. This, also, may 
readily be confounded with aneurism of the aorta, 
or of the subclavian artery. In April, 1826, we 
saw a case at Guy's Hospital, which led to much 
deliberation respecting the propriety of taking up 
the carotid above a pulsating tumour, supposed to 
be an aneurism of that artery. It was finally de- 
cided that the tumour was too low, and the design 
was judiciously abandoned. The affection proved 
to be a dilatation of the aorta and arteria innomi- 
nata. The carotid was sound. This state of 
parts was indicated to us by the stethoscope. Mr. 
Hodgson met with a similar case. (On the Dis- 
eases of Arteries, p. 90.) 

11. The superior and middle parts of the chest 
are dull on percussion. But this sign is common 
to an infinity of other diseases, and the resonance 
is seldom impaired unless the aneurism be very 
large. 

It cannot be a subject of surprise that a series 
of symptoms liable to so many fallacies, should 
have proved insufficient, without the aid of auscul- 
tation, to dissipate the deep obscurity involving the 
diagnosis of aneurisms of the aorta. We have 
next to consider the second class of signs, namely, 
II. Signs of aortic aneurism afforded by 

auscultation, percussion, &c. 

The investigations of M. Laennec on aneurism 
of the thoracic aorta, were limited and inconclu- 
sive. Accordingly, he remarks that, " Of all the 
severe lesions of the thoracic organs, three alone 
remain without pathognomonic signs to a practi- 
tioner even in auscultation and percussion, — 
namely, aneurism of the aorta, pericarditis, and 
concretions of blood in the heart previous to death. 

" Taking the part of auscultation against its 
immortal discoverer," we hope to show that there 
is now little difficulty in the diagnosis of the three 
affections in question. We shall first present the 
opinions of Laennec, and then offer the results ot 
our own observation. 

Laennec's opinions respecting the stethoscopn, 
signs of aneurism of the aorta are as follows : — 
On applying the cylinder, in two instances, to 
tumours presenting externally, he found that their 
pulsations were exactly isochronous with the 
pulse ; that the shock and sound greatly exceeded 
those of the ventricles ; that the beating was dis 
tinctly audible on the back ; and that the auncu 
lar sound could not be distinguished at all. Foi 
the last reason he denominated the aneurismal 
pulsation simple, in contradistinction to that of 
the heart, which has a double sound, in conse- 
sequence of the alternate systole and diastole r>( 



134 



AORTA, (ANEURISM OF THE) 



the ventricles* From these two cases he fell 
certain that, in some instances, pectoral aneurisms 
might be recognised by the simple pulsation, usu- 
ally much stronger than that of the heart ; hut 
he thought that, in a larger proportion of cases, 
the sign would be insufficient, for, as the slightest 
dilatation of the heart renders its sounds audible 
over the whole sternum, and even below and along 
the clavicles, he imagined that, under such cir- 
cumstances, the first or systole sound of that organ 
would be confounded with the sound of the aneu- 
rism, with which it is synchronous; while the 
second, or diastolic sound, being audible as far as 
the tumour, would lead the auscultator to suppose 
that he there heard the beating of the heart, and 
not that of the aneurism. We shall presently 
show that this reasoning is incorrect. As the au- 
ricular sound is not audible over the abdomen, 
Laennec found no difficulty in recognising ventral 
aneurisms by the simple pulsation. 

According to our experience, the cylinder is 
scarcely less capable of affording decisive indica- 
tions of pectoral than of ventral aneurism. It is 
unimportant whether the pulsations be "simple" 
or "double,-" for, though double, they may be 
distinguished from the beating of the heart by un- 
equivocal criteria : viz. — 

1st. The first aneurismal sound, coinciding with 
the pulse, is invariably louder than the healthy 
ventricular sound, and generally than the most 
considerable bellows-murmurs of the ventricles. 

2d. On exploring the aneurismal sound from its 
source towards the region of the heart, it is found 
to decrease progressively, until it either becomes 
totally inaudible, or is lost in the predominance of 
the ventricular sound. Now, if the sound ema- 
nated from the heart alone, instead of decreasing 
it would increase on approximating towards the 
precordial region. 

3d. The second sound actually does sustain this 
progressive augmentation on advancing towards 
the heart; and, as its nature and rhythm are found 
to be precisely similar to those of the ventricular 
diastole heard in the precordial region, it is dis- 
tinctly identified as the diastolic sound. The. 
second sound, therefore, corroborates rather than 
invalidates the evidence of aneurism afforded by 
the first ; for if both sounds proceeded from the 
heart, both would, on approximating towards it or 
receding from it, sustain the same progressive 
changes of intensity. 

4th. Another distinctive characteristic of the 
aneurismal pulsation is the peculiar nature of its 
sound. It is a deep hoarse tone, of short duration, 
with an abrupt commencement and termination, 
and generally louder than the most considerable 
bellows-murmurs of the heart. It accurately re- 
sembles the rasping of a sounding-board heard 
from a distance ; whereas the sound occasioned 
by valvular disease of the heart has more analogv 
to the bellows-murmur, being somewhat soft and 
prolonged, with a gradual swell and fall. It ap- 
pears probable that the greater hoarseness and 



* II is necessary to remind the rcadrr that the systole 
of the auricles was regarded by Laennec a-* the cause of 
me second sound; but, according to the experiments and 
researches of the writer, the diastole of the ventricles is 
the cause of that phenomenon. Vide Loud. Med. Gaz. 
.lug. 1830, and a Treatise on the Discuses of the Heart, 
->v the writer 1831. 



loudness of the aneurismal sound above than below 
the clavicles, is attributable to its being reverbera- 
ted through the chest before it arrives at the ear. 
This probably is countenanced by the following 
consideration's :—(«•) That, in several cases with 
which we have met,f although the sound above 
the right clavicle was loud and hoarse, it was 
merely a whizzing (sifflement) without hoarse- 
ness on the superior part of the sternum, where 
the dilated ascending aorta was in apposition with 
the bone, and where, consequently, the sound was 
transmitted immediately to the ear. (Jj.) That, in 
the heart, the proximity of which organ to the 
thoracic parietes is unfavourable to the expansion 
and reverberation of its sounds, morbid murmurs 
are less hoarse and loud than those occasioned by 
pectoral aneurisms, (c.) That in aneurisms of 
the abdomen and extremities, where there is little 
or no reverberation of sounds, there is a still less 
degree of hoarseness and loudness. 

The abruptness of the aneurismal sound, com- 
pared with the prolonged swelling character of the 
ventricular murmur, is owing to the latter being 
generated by a gradual muscular contraction, while 
the former is due to the sudden propulsion of a 
fluid through a tube naturally very resistant, and 
rendered still more unyielding by disease. The 
loudest aneurismal sound is that occasioned by 
dilatation, and it has more of the grating or rasp- 
ing character in proportion as the interior of the 
vessel is more overspread with hard and especially 
osseous asperities. When the dilatation is con- 
fined to the ascending aorta, the sound, impulse, 
and purring tremor are stronger on the right than 
on the left side of the neck ; and the sound along 
the mesial part of the sternum — the tract of the 
ascending aorta — is superficial, and of a whizzing 
or hissing character. Old aneurisms, the parietes 
of which are thickened by fibrinous depositions, 
yield only a dull and remote sound. In all cases 
of dilatation, and in the majority of sacculated 
aneurisms, the sound is loudest above the clavi- 
cles, even though the impulse be stronger below. 
In some cases of the sacculated species it is louder 
on the side of the neck opposite to that where the 
tumor exists. We have found this to proceed 
from one or other of two causes — first, disease of 
the inner coat of the aorta before or beyond the 
tumor ; secondly, the interposition of the sac, 
thickened with fibrinous layers, between the aorta 
and the super-clavicular region, in consequence of 
which the source of sound, — the mouth and cavity 
of the sac, — was unusually remote on the side 
occupied by the tumor. 

The sound of aneurisms is, in most instances, 
audible on the back ; and when the tumor occu- 
pies the descending aorta, and is extended along 
the spine, it is often louder behind than on the 
breast. If it possesses on the back the abrupt 
rasping character, the evidence which it affords is 
almost positive ; for the loudest sounds of the 
heart, when heard on the back, are so softened and 
subdued by distance, as totally to lose their hardi- 
ness. 

5th. Purring tremor is another characteristic 
of the aneurismal pulsation. It is more conside- 
rable in simple dilatation than in sacculated aneu- 

1 Se^ for instance, Case 9. Land. Med Oaz. September 



AORTA, (ANEURISM OF THE) 



13--) 



rism, particularly if the former be accompanied 
with much asperity of the internal membrane. 
From numerous dissections, the fact appears to 
us to admit of the following explanation : — in 
cases of dilatation, the interior of the vessel is al- 
most invariably rendered rugged by osseous, carti- 
laginous, or other adventitious depositions ; and 
the blood, in permeating such a tube, necessarily 
occasions a strong tremor, as its particles are 
thrown into preternatural commotion and colli- 
sion, not only by the enlargement of the caliber 
of the vessel at the dilated part, by which they are 
diverted from their direct course, but also by the 
roughness of the surface over which they have to 
pass. In sacculated aneurism, on the contrary, 
though a portion of blood descends into the sac, 
the greater quantity pursues a direct and tranquil 
course through the smooth canal of the artery, 
and the tremor is therefore less considerable. 

We have uniformly found the purring tremor 
confined to the superclavicular regions, except in 
the case of aneurisms which had protruded through 
the ribs, and presented immediately underneath 
the integuments. It is rarely occasioned at all by 
old aneurisms; because, in consequence of their 
magnitude and the thickening of their sacs with 
fibrinous coagula, they possess little susceptibility 
of vibration. 

Purring tremor, proceeding from organic dis- 
ease of the aorta, may easily be distinguished from 
that occasioned by nervous agitation. The for- 
mer is constant, or may be excited at pleasure, 
simply by accelerating the circulation ; it is re- 
stricted to a limited space above the sternal extre- 
mities of the clavicles, and is accompanied with 
the hoarse aneurismal sound. Nervous purring 
tremor, on the other hand, is only occasional, oc- 
curring when there is an exacerbation of nervous 
excitement and restlessness ; it extensively per- 
vades the adjoining arteries, and the concomitant 
sound is comparatively soft and feeble. 

Pulsation attends every species of enlargement 
of the aorta. In dilatation, it exists only above 
the sternal ends of the clavicles, and always on 
both sides of the neck simultaneously ; though, 
when the enlargement is confined to the ascend- 
ing aorta, it is stronger on the right than on the 
left side. When dilatation is of a pouched form, 
and of great magnitude, it may occasion pulsation 
under the sternum. Of this we have met with 
instances. Carotid and subclavian aneurisms pro- 
duce impulse, sound, and tremor, on the affected 
side only, and by this circumstance they may 
easily be discriminated from aortic enlargements. 

In sacculated aneurism seated in the upper parts 
of the chest, pulsation exists both above and be- 
low the clavicles; but I have generally found it 
stronger below. When the tremor is large, and 
occupies the left extremity of the arch, the im- 
pulse is often perceptible from the sternum to the 
left shoulder, and as low down as the third or 
fourth rib. When it lies in contact with the ribs 
posteriorly, the shock is sometimes felt on the 
back. This, however, is a rare occurrence. A 
pulsation under the sternum or ribs is one of the 
least ambiguous signs of sacculated aneurism. 

Summary of the stethoscopio, in con" 
junction With the general, signs of aortic 
aneurism. 

Simple dilalation of the arch, and ascending 



aorta. Stethoscopic signs. — 1st. A constant pul- 
sation above both clavicles at their sternal ends ; 
stronger on the right side if the enlargement is 
confined to the ascending portion, and never com- 
municated to the sternum or ribs unless the dila- 
tation is enormous. 2. A hoarse rasping sound 
above both clavicles, of brief duration, commencing 
and terminating abruptly. If the enlargement is 
confined to the ascending portion, the sound is 
louder above the right than the left clavicle, and 
along the middle of the sternum it is superficial, 
and of a hissing or whizzing character ; by which, 
and by the sound being situated higher up the 
chest, it is distinguishable from that of valvular 
disease. It is usually distinct on the back, where 
the ventricular sounds, if audible at all, are very 
obscure. 3. A purring tremor above the clavicles, 
but never below. It is stronger, and the conco- 
mitant sound is more grating, in proportion as the 
interior of the aorta is more overspread with hard 
and especially osseous inequalities. 

General signs of dilatation. Frequently none. 
When any exist, they are a slight degree of those 
common to all organic diseases of the heart, viz. 
the signs of an embarrassed circulation. They 
assume a most aggravated aspect when dilatation 
becomes complicated with organic disease of the 
heart. 

Fallacies, and methods of delecting them. 

(cr.) Nervous arterial excitement and reaction 
after loss of blood, sometimes occasion an impulse 
and bellows-sound above the clavicles ; but they 
may be discriminated by the impulse being feeble, 
and the sound more hissing or whizzing than in 
aneurism of the aorta, and by the absence of pur- 
ring tremor. It is, in fact, in the subclavian arte- 
ries that the phenomena take place ; for though 
the aorta be under the same excitement, its action 
is not so violent as to extend in any appreciable 
degree to the supra-clavicular regions. 

(6.) Adhesion of the pericardium, particularly 
when accompanied with hypertrophy of the heart, 
we have, in many instances, found to occasion the 
impulse and whizzing sound above the clavicles 
in a still more remarkable degree than nervous 
excitement. The phenomena depend upon the 
suddenness, and, as it were, spasmodic energy of 
the ventricular contraction. They may be distin- 
guished by the sound being more whizzing and 
less hoarse, and the impulse more jerking, than in 
dilatation of the aorta ; and they should always 
be suspected to proceed from adhesion, when the 
heart presents the signs, and the history affords 
the presumption of that affection. 

(c.) Dilatation of the pulmonary artery is , 
third, though extremely unfrequent, source of fal- 
lacy : for the mode of detecting it we refer the 
reader to the next head, viz. 

Dilatation of the pulmonary artery. - We 
have met with one case in which this artery was 
dilated to the extent of five inches in its internal 
circumference. It presented the following signs. 

1. A pulsation with purring tremor between 
the cartilages of the second and third ribs on the 
left side, and thence in a decreasing degree down- 
wards, but not appreciable above the clavicles. 
Also a slight prominence between the same ribs. 

2. An extremely loud, superficial, harsh, saw 
ing *oi-nd, audible above the clavicles and over 



136 



AORTA, (ANEURISM OF THE) 



the whole precordial region, but loudest on the 
prominence between the second and third ribs. 

General signs were those of hypertrophy and 
dilatation of the heart, with which the dilatation 
of the pulmonary artery was complicated. 

Fallacies, and the methods of detect in? them. 

Dilatation and aneurism of the aorta are per- 
haps the only affections for which dilatation of the 
pulmonary artery could be mistaken. The signs, 
however, of the latter arc so characteristic, that, 
with due attention, it is scarcely possible to com- 
mit an error. Thus, a pulsation between the car- 
tilages of the second and third ribs could not be oc- 
casioned by a dilatation of the ascending aorta ; as 
this artery, even when dilated, is too far to the 
right to extend beyond the margin of the sternum. 
Again, a sacculated aneurism of the ascending 
aorta could not reach the cartilages of the second 
and third left ribs without being very large, and 
in this case it would form a much greater tumour 
externally than existed in the present instance. 
The sound also of such an aneurism would be 
dull, and as if remote, instead of loud and super- 
ficial. Finally, cither a dilatation or an aneurism 
of the aorta would occasion a greater pulsation 
and sound above one or both clavicles, than ex- 
isted in the case of which we speak. 

Sacculated aneurism of the thoracic aorta. — 
Stethoscopic signs. 1. A pulsation both above 
and below the clavicles, but usually stronger be- 
low. If the tumour occupies the ascending aorta, 
its impulse is most perceptible on the sternum, 
and towards its right. If it is seated in the arch 
or commencement of the descent, the pulsation in- 
clines to the left side, and sometimes reaches to 
the shoulder. It is occasionally perceptible on 
the back. In front, the pulsation is always 
stronger on the tumour than at some point inter- 
mediate between it and the heart, and generally 
stronger than the impulse of the heart itself. 

2. The aneurismal sounds described under dila- 
tation, but weaker. In large, old aneurisms, it 
has a dull and remote character, and is sometimes 
louder on the side of the neck opposite to that 
where the tumour is situated. It is generally 
audible on the back ; and when the tumour occu- 
pies the descending aorta, it is often louder be- 
hind than in front. If, on the back, it has more 
of the abrupt, rasping sound than the ventricular 
systole in the precordial region, the evidence of 
aneurism is almost positive. 

3. A purring tremor above the clavicles. We 
have never found it below, unless the tumour had 
penetrated through the ribs or sternum. It is 
weaker than in dilatation, and in old and large 
aneurisms often becomes extinct. 

General signs of sacculated aneurism. — Any 
or all of the following signs may be present. A 
pulsating tumour, presenting externally, and soon- 
er or later causing livid redness of the integu- 
ments ; deficient resonance on percussion ; a sense 
of retraction of the trachea, with a wheezing respi- 
ration and croaking or whispering voice ; dyspha- 
gia ; an intense gnawing or boring pain in the. 
spine ; aching of the left shoulder, scapula, neck, 
axilla, and arm, with numbness, formication, and 
impaired motive power of the limb ; a sense of 
weight and infarction in the chest ; difference of 
•he two pulses : purring tremor of the radials : 



some or other of the ordinary symptoms of organic 
disease of the heart. 

Fallacies, and the methods of detecting Hum. 

Pulsation beneath the sternum and ribs, occa- 
sioned by amplified glands, or other tumours in 
the anterior mediastinum, by hydropericardium, 
by enlarged heart, or, finally, by adhesion of the 
pericardium, may, according to our experience, ba 
easily discriminated from aneurismal pulsation by 
the following criteria. 

(a.) Pulsating glands, or other tumours in the 
anterior mediastinum, are not attended with the 
aneurismal sound ; and symptoms of a disturbed 
circulation either do not exist at all, or do not cor- 
respond in severity with the magnitude of the ap- 
parent disease, (b.) Hydropericardium, instead 
of producing the gradual, steady, and powerful 
heaving of an aneurism, occasions an undulating 
motion, of which some of the shocks are stronger 
than others, and none are exactly synchronous 
with the sound of the ventricular systole. The 
motion is equally diffused over every part of the 
space occupied by the fluid ; whereas in aneurism 
the impulse is notably stronger on the tumour and 
on the heart, than on the intermediate space. Hy- 
dropericardium is not productive of the aneurismal 
sound. Its history is different from that of aneu- 
rism, the latter being very often referred to some 
injury or excessive exertion, suddenly followed by 
pain or dyspnoea, (c.) An enlarged heart causes 
a pulsation over a preternatural extent in every 
direction ; an aneurism occasions it in its own 
direction alone. The beating of an enlarged heart 
is strongest at the point nearest to the centre of 
motion, and it decreases progressively on receding 
from that centre : the beating of an aneurism is 
stronger on the tumour than at some point inter- 
mediate between it and the heart ; and in most 
instances it is stronger even than the beating of 
the heart itself. Hence, an aneurism distinctly 
conveys the impression of their being two centres 
of motion — the tumour and the heart ; while the 
pulsation of an enlarged heart is felt to be refera- 
ble to one alone. Finally, the ventricular con- 
traction of a dilated heart produces a loud flap- 
ping sound, and is not attended with aneurismal 
murmur or pulsation above the clavicles. We 
have never known adhesion of the pericardium to 
occasion a pulsation which could be mistaken for 
an aneurism, until it had occasioned enlargement 
of the heart, its ordinary consequence. In this 
case the diagnostic symptoms are the same as 
those of enlargement of the heart, with one dilTer- 
cp.ee. that the motion is of a more unsteady, un- 
dulating, and struggling character, (</.) Yarix 
of the jugular rein, occasioning pulsation above 
the clavicle, is distinguished by the absence ot 
sound, the compressibility of the humour, and the 
languor of the impulse, (e.) Enlarged glands, 
or other tumours above the clavicles, receiving 
pulsation from a subjacent artery, rarely occasion 
sound ; and if any exist, it is a feeble whizzing. 
Both it and the pulsation are confined to the side 
affected. If the tumour can be grasped, it will be 
felt not to dilate laterally during the ventricular 
contraction ; and if it can be raised from the sub- 
jacent artery, its beating will cease entirely. (/•) 
Subclavian and carotid aneurism occasion pulsa- 
tion, sound, and purring tremor on the affected 



AORTA, (ANEURISM OF THE) 



137 



side only, and these signs are more superficial and 
distinct than in aneurism of the aorta. The sound 
resembles that of the small hand-bellows, instead 
of having the hoarseness of the forge-bellows, 
(if.) Purring tremor of the chest, proceeding 
from mucous rattle, may be recognised by its ceas- 
ing when respiration is suspended. 

Sacculated aneurism of the abdominal aorta 
is comparatively so easy of detection, that we 
have not thought it necessary to enter into detail 
respecting its signs. 

Stetkoscopic signs 1. A constant pulsation 

of extraordinary power. It appears much stronger 
to the car resting on the stethoscope than to the 
hand. The instrument may be forced down in 
various directions into close proximity with the 
tumour, and an idea of its position and dimen- 
sions may be thus obtained. 2. A loud, brief, 
and abrupt bellows-sound, not so hoarse as that 
of aneurisms in the chest. It is sometimes audi- 
ble on the back. The diastolic sound of the heart 
is inaudible, and, consequently, the pulsation is 
simple. 

General signs They are those of impeded 

respiration dependent on an imperfect descent of 
the diaphragm ; of lumbar abscess, with or with- 
out caries of the vertebra? ; of renal disease ; and 
of pressure on the nerves or viscera of the abdo- 
men and pelvis ; but none are pathognomonic of 
aneurism, except a pulsating and usually compres- 
sible tumour, felt through the abdominal parietes. 

Fallacies, and methods of detecting them. 

(a.) A scirrhous tumour of the stomach. (Z».) 
Enlargement of the pancreas by hydatids, or 
scirrhus — an extremely rare affection, (c.) Fun- 
goid, or other tumours of the mesentery, omen- 
tum, transverse arch of the colon, or diaphragm. 
(d.) Indurated fxces, air, or masses of tape- 
worm, impacted in the transverse colon. When 
any of these tumours rest upon the aorta, they 
receive its pulsation, and frequently occasion a 
bellows-sound by compressing the vessel. They 
may be discriminated from aneurism by their im- 
pulse being comparatively feeble, particularly 
when the stethoscope is applied laterally ; by the 
sound being only a slight whizzing ; by the 
tumour feeling incompressible ; by its being su- 
perficial when connected with the stomach, colon, 
or omentum ; and by its moving with the move- 
ments of these viscera. Finally, the general 
symptoms are those of dyspepsia, or of malignant 
disease, with slow and progressive marcor, with- 
out derangement of the circulation, (e.) An ac- 
cumulation of serum in the peritoneal cavity is 
another source of fallacy, as the liquid transmits 
both the impulse and the sound of the aorta more 
distinctly than natural. Dr. Young made this 
discovery in 1815.* As it is easy to detect the 
fluid, we have never found this source of fallacy 
to occasion the least embarrassment. 

Xcrcous pulsation of the abdominal aorta 

This is a very frequent and deceptive affection in 
irritable and hysterical constitutions. When it 
exists in conjunction with air pent up in the colon 
or duodenum and presenting the feel of a com- 
pressible tumour, the resemblance to aneurism is 



*Mcd. Trans, of Coll. of Phys. of London, vol. v. 
1815. No. J.5. 

Vol. I.— 18 M * 



still more complete. After an examination of 
many cases, we are satisfied that attention to the 
following circumstances will render the diagnosis 
easy. The cylinder may be pressed down on the 
aorta so as to yield a distinct feel of the vessel of 
its natural caliber. The sphere of its pulsation is 
limited transversely, but extensive longitudinally; 
being usually more or less perceptible from the 
epigastrium to the bifurcation. The impulse, in- 
stead of being the gradual, steady, and irresistible 
heaving of an aneurism, is a smart, though vigor- 
ous jerk; and the sound, when any exists, is 
merely a whizzing, almost devoid of hoarseness. 
The general symptoms are nervous or hysterical, 
and the pulsation is of an inconstant character, 
increasing and diminishing with the exacerbations 
and remissions of the constitutional excitement. 
Spontaneous cure, and medical treat- 
ment OF ANEURISM OF THE AORTA. 

Previous to entering upon the treatment of 
aneurism of the aorta, we shall explain the 
mechanism by which its spontaneous cure is 
effected, as the reader will thus be better enabled 
to understand the principles on which the treat- 
ment is founded. 

The movement of the blood within the sac 
being retarded, partly by the roughness of its in- 
ternal surface, and partly by the fluid being with- 
drawn from the direct channel of the circulation, 
coagulation takes place, and lymph is deposited 
and organized in successive strata, until the cavity 
is at length completely filled. The sac, being 
then no longer exposed to the distensive pressure 
of the circulation, tends to contract by its own 
resilience and the compression of the incumbent 
parts, absorption of its contents takes place, and 
the aneurism is finally reduced to a small, dense, 
flesh-like tumour. In arteries of the second and 
inferior orders, the coagulum generally extends to 
and obliterates the caliber of the vessel itself ;| 
but this is rarely the case in the aorta, as the force 
of the circulation in so great a vessel prevents the 
lodgement of coagula. Instances, however, of 
obliteration of the aorta by lymph are not without 
example. An important case has been published 
by our friend Professor Alexander Monro,t and 
Dr. Goodison describes another. 

It is principally in false aneurism that the cure 
by deposition of coagula takes place. In true 
aneurism, and in dilatation, such a cure is very 
rare ; for the walls being unbroken and smooth, 
and the aperture of communication with the sac 
being in general large, the blood is seldom arrest- 
ed to such a degree as to deposit lamellated 
coagula. When, however, the whole circumfer- 
ence of an artery is converted into a bony cylin- 
der, there is a great tendency to its obliteration by 
a plug of lymph. Dr. Goodison's case was of 
this description : and we have more than once 
witnessed the same in arteries of the second order. 

Hence, as the formation of coagula within the 
sac is the principal means employed by nature in 
effecting the cure of aneurisms, the primary oh 
ject of medical treatment is to promote the depo- 
sition of coagula ; and this is best accomplished 



fVide Hodgson, Jones, Farre, Baillie, Petit, Desautr, 
and Scarpa. 

X Observations on Aneurism of the Abdominal .Apria, 
by Professor Monro, ed. p. 5 and 8, 1k27. 



138 



AORTA, (A N E I IK 1 S M OF THE) 



by such means as have the greatest effect in en- 
feebling and retarding the circulation. Accord- 
ingly, the antiphlogistic treatment, rigorously pur- 
sued, is the most cilieient remedy for aneurism of 
the aorta. This has acquired great celebrity un- 
der the designation of the treatment of Alhertini 
and Valsalva. By detraction of blood and spare 
diet, they reduced their patients to so extreme a 
state of debility, that they were scarcely able to 
raise their arms from the bed. Morgagni reports 
(Epist. xvii. art. 30.) that when Valsalva had 
taken away as much blood as was requisite, he 
made it a custom to diminish the quantity of meat 
and drink more and more every day, till he pro- 
ceeded so far as to allow only half a pound of 
pudding in the morning, and in the evening half 
that quantity, and nothing else except water, and 
this also within a certain weight. After he had 
sufficiently reduced the patient by this method, so 
that, from weakness, he could scarcely raise his 
hand from the bed, in which he lay by Valsalva's 
order from the very beginning of the disease, he 
increased, by degrees, every day, the quantity of 
aliment until the necessary strength returned. 

To render this treatment safe and efficient, 
several circumstances must be taken into con- 
sideration. In persons of very feeble constitution, 
its employment is inadmissible, as it might be fatal 
by inducing other diseases, or irremediable de- 
bility. In individuals sufficiently strong to un- 
dergo the treatment, but in whom there is reason 
to apprehend that extreme, debility, if long con- 
tinued, might occasion pernicious effects, this 
state, when once induced, should be speedily re- 
moved. The depleting system should be actively 
pursued in the first instance, so as to make a 
decidedly enfeebling impression on the circulation, 
and thus allow of the contraction of the sac and 
tie deposition of a coagulum ; but when the pulse 
and general feelings of exhaustion indicate that 
the impression has been made, its protracted con- 
tinuance should be prevented by a spare, but 
nutritious diet, as a little strong beef-tea or mut- 
ton-broth. The quantity of blood to be drawn 
must depend upon the constitution of the patient 
and the effect produced. In one case under our 
care, ^x. were abstracted for sixteen days conse- 
cutively, with an excellent result. Others we 
have seen bled to §x. or xii., twice a day, for six 
or seven days ; and this practice was pursued by 
Pelletan* and others; but we have found the 
best effect to be produced with the least expendi- 
ture of blood by drawing a considerable quantity, 
as from §xv. *° xxv., in the first instance, and 
repealing the bleeding to %x. or xv., within twelve 
hours, and then taking ^vi. or viii., every six or 
right hours, or at such intervals as to prevent the 
establishment of re-action — a phenomenon, which, 
by producing an inordinate energy of the circula- 
tion, counteracts the effect of the depletion. Of 
this we can entertain no doubt, both from exten- 
sive observation on the human subject, and ex- 
periments on dogs ; in the latter of which we 
have seen bleeding, repeated daily or every second 
day for ten days, occasion the most violent arterial 
ihrobbing.j- In individuals who have not suf- 

* Clinique Chirurg. torn i. Prem. Mem. sur les Aneu- 
lWmes, p. 54. 
tTliis subject has been developed with great ability, 



ficicnt constitutional vigour to give rise to much 
re-action, less frequent and more sparing detrac- 
tions of blood will suffice, as, for instance, from 
Svi. to xii., two, three, or four times a week. 
The blood after repeated abstractions becomes 
very serous, of a pale crimson instead of the 
natural dark venous colour, and has sometimes g 
whitish cream on its surface after standing twelve 
hours. . 

In aneurism of the aorta, especially when con- 
joined with organic disease of the heart, the bleed- 
ing should never, if possible, be carried to syn- 
cope, as, in such cases, this phenomenon is apt to 
be alarmingly protracted, and sometimes to termi- 
nate fatallv. The blood, therefore, should be 
drawn slowly, and in the recumbent posture. Nor 
should the venesection be performed during a 
paroxysm of palpitation, as the exhaustion conse- 
quent on it, superadded to that occasioned by the 
loss of blood, not unfrequently sinks the patient 
beyond the possibility of restoration. When 
there is much pain in the tumour, leeches afford 
great relief to it, while they, at the same time, 
conspire to reduce the circulation ; but they should 
not be applied when the integuments are very 
thin and discoloured, as they are apt to induce 
sloughing and rupture of the sac. Ice, as an ap- 
plication to the tumour, has been strongly recom- 
mended ; but the pain which it produces, is, in 
general, intolerable beyond a short time. Its 
occasional use, however, and, in the intervals, a 
cold cataplasm of linseed-meal and vinegar, are 
very serviceable, by contracting all the tissues and 
promoting the coagulation of the blood within the 
sac, when its current has been rendered languid 
by depletory measures. When cold applications 
are not employed, and the tumour is painful and 
requires support, we have found the emplastrum 
belladonna? afford the greatest relief. 

The diet should consist principally of fluids, and 
it should be gradually reduced. Pelletan some- 
times allowed only two basins of broth in twenty- 
four hours, and lemonade as a common drink. 
Valsalva, as before stated, gradually reduced the 
food to half a pound of pudding in the morning, 
and a quarter of a pound in the evening, with a 
limited quantity of water. By thus gradually 
reducing it both in quantity and quality, the solids 
may easily be brought as low as four ounces, and 
the fluids as eight, daily. In some even less is 
sufficient, and this for weeks together. Both the 
body and the mind should be kept in a state of 
the most perfect quietude. The recumbent posi- 
tion should be constantly maintained. Purgatives 
which have a great effect in weakening the action 
of the heart, should be frequently administered. 
Digitalis is useful by producing the same effect; 
but it should not be pushed so far as to bring tin- 
patient strongly under its influence, as the syncope 
induced by this drug is liable, in affections" of the 
heart and aorta, to be fatal. We have several 
times seen it extremely alarming. 

The well-known effect of the superacetatc of 
lead in controlling active hemorrhages, has intro- 
duced this as a remedy for aneurism. In Germany 
it has been extensively used for many years, ami 
Dupuytren, Laenncc, and Bertin have employed 

by Dr Marshall Hall, in conrert with whom we 3cr- 
formed the experiments alluded to. ' 



A P HO IN I A . 



139 



it with advantage in France. Our own experience 
is in its favour. Its tendency to produce colic, 
and inflammation of the mucous membrane of the 

stomach and intestines, may be counteracted by 
conjoining it with opium, and commencing with 
a small dose. Half a grain of each, gradually 
increased to a grain of the acetate in a pill, three 
or four times a-day, is the form in which we 
employ it. Any gastric irritation from it we have 
always found to be removed by a dose or two of 
castor-oil promptly administered, and mucilagi- 
nous diluents. When the patient has been re- 
duced as low as the constitution will bear, the 
state of the aneurism should be examined with the 
utmost attention. If it has undergone no amelio- 
ration, the treatment should be abandoned rather 
than the risk incurred of reducing the patient 
further, and beyond the power of the constitution 
to sustain. But if it is clear that, the pulsation 
and sound of the aneurism are greatly diminished 
or entirely suppressed, and the volume of the 
tumour reduced, the practitioner is justified in 
persevering, — so far as he can do it without bring- 
ing the life of the patient into palpable danger. 
'When the amelioration has become confirmed, the 
treatment should be gradually relaxed, but absti- 
nence and the recumbent position should be en- 
forced, even for a considerable period after all the 
symptoms have disappeared. 

The treatment of Albertini and Valsalva should 
not be adopted in a rigorous manner, and with a 
curative view, unless the practitioner has reason 
to believe that the aneurism is of the false species, 
viz. by rupture of the arterial tunics ; or, if of the 
true species, that the sac is not a mere pouch, but 
so deep, and with so narrow a neck as to be con- 
siderably removed from the direct current of the 
circulation. The latter state may be presumed 
with some confidence when the tumour, supposing 
it to spring from the ascending aorta, extends far 
to either side ; or, whatever be its situation, when 
its base is remote from the caliber of the artery. 
Aneurisms of the descending aorta may be treated 
as false : post-mortem inspection having proved 
that they are almost always of that description. 
In cases of dilatation, and of shallow true aneurism, 
the antiphlogistic plan should be pursued to a 
moderate extent only, and merely with a palliative 
object : for as, under such circumstances, coagula 
scarcely ever form, a radical cure is not to be. 
expected. 

It may be said, finally, that the efficacy of the 
treatment of Albertini and Valsalva has, in all 
probability, been somewhat over-rated. For, as 
the diagnosis of aneurisms of the aorta was in- 
volved in much obscurity until the last few years, 
it is certain that many cases, reported as cured, 
were not aneurisms, but tumours or nervous pul- 
sation simulating that disease. Another reason 
has prevented the treatment from maintaining its 
ground, namely, its severity. Though patients 
will submit to rest and extreme abstinence, they 
have rarely fortitude to see bloodletting superadded. 
The practitioner, on the other hand, has seldom 
the courage to insist upon it, knowing that it is 
not wholly exempt from danger, and that it will 
not infallibly be productive of a cure, especially if 
not pursued with uncompromising rigour. 



Treatment of nervous pulsation of the 

aorta. — Though the treatment of nervous pulsa- 
tion does not strictly come under the head of aneu- 
rism, yet, as the pulsation is a frequent concomi- 
tant of aortic aneurtsms and organic diseases of 
the heart, it may not be foreign to our present 
purpose to advert briefly to its treatment. 

The indication is, to allay the nervous irrita- 
bility and excitement on which the pulsation de- 
pends. This may be effected by causing the pa- 
tient to maintain, as far as possible, a tranquil 
state of body and mind ; by a mild cooling diet 
and regular state of the bowels ; by sedative reme- 
dies, as conium, hyoscyamus, camphor mixture ; 
and by these conjoined with antispasmodics, as 
assafcetida, valerian, sulphuric sether, if there be 
hysterical symptoms. It is scarcely necessary to 
add, that attention to the catamenial secretion is 
of primary importance. When the patient is suf- 
ficiently tranquillized to bear tonics and stimulants, 
the best remedies are the various preparations of 
steel, with infusions and decoctions of cinchona, 
cascarilla, columba, orange-peel, &c, the shower- 
bath, much out-door exercise short of fatigue, and 
a nutritious but not heating diet. 

J. Hope. 

[AORTA, inflammation of the. See Ar- 
teritis.! 

APHOJNTA (from a privativum, and <puv>i, vox) 
is the term used by nosologists to designate that 
privation or suppression of voice, more or less 
complete, which occasionally takes place indepen- 
dently of coma or syncope. Dr. Cullen has ar- 
ranged it in the class Locales, and in the order 
Dyscinecix, (or impeded and depraved motions, 
from a fault of the organs ;) and has enumerated 
three species ; viz : 

1. Aphonia gutturalis, from tumefaction of the 
fauces and glottis : 

2. Aphonia trachealis, from tumours of neigh- 
bouring parts compressing the trachea : 

3. Aphonia atonica, from mechanical division, 
or paralysis, of the nerves distributed to the tongue 
and larynx. 

In all these species the loss of voice is only 
symptomatic; and purely owing to the preterna- 
tural condition of the vocal organs. Indeed it is 
very doubtful whether aphonia is ever an idiopa- 
thic affection. In many cases of severe catarrh 
it is an attendant symptom, and depends upon the 
lining membrane of the larynx being slightly in 
flamed and thickened -, in the same manner as the 
Schneiderian membrane of the nose is thickened 
when we are incommoded by the sensation fami- 
liarly called " stuffing in the head." 

Again, in many instances aphonia precedes or 
succeeds apoplexy ; but in such cases it is indica- 
tive of plethora, or pressure, within the cranium, 
and is always to be regarded as a formidable symp- 
tom, not from the mere inconvenience of the loss 
of voice, which is only a subordinate matter, but 
from the proof it affords that the internal cause, 
whatever it be, that interrupts the nervous influ 
ence, is situated about the base of the brain, and 
probably in the medulla oblongata, the part from 
which the nerves of the tongue originate. The 
medulla oblongata, where the crura of the cere- 
bruin and cerebellum effect a junction with the 



140 



APHONIA — APHTHJB. 



spinal chord, scorns to be the great centre of ner- 
vous union and sensorial power. Hence it has 
been accounted by pathologists the part of the 
nervous system most indispensable to life. Ac- 
cording v, in those cases of apoplexy where the 
speech is much or permanently affected, our prog- 
nosis, for the reasons aforesaid, ought to be always 
unfavourable. Discussions of this kind, however, 
more properly belong to the head of apoplexy. 

We have sometimes met with aphonia depend- 
ing upon atony, or relaxation of the vocal chords, 
in consequence of long-continued over-exertion 
of the voice in speaking, shouting, singing, or the 
like. 

It is also now and then caused by ulceration of 
the lining membrane of the larnyx and its carti- 
lages ; a disease that gives rise to rapid emaciation, 
hectic fever, profuse expectoration of frothy mu- 
cus, and the other frightful symptoms known to 
modern practitioners under the name of phthisis 
laryngea. A fatal case of this sort, most distress- 
ing in all its details, lately came under our ob- 
servation, where the ulceration of the cartilages of 
the larynx occurred as the sequela of syphilis. 

For the most part, however, aphonia, where it 
occurs without any palpable disorder, or structural 
lesion, of the organs of speech, is a modification 
of hysteria ; that Protean malady which assumes 
such various shapes and hues, and gives rise to 
such irregular, anomalous, and perplexing symp- 
toms ; resisting for months, or even years, the 
most assiduous and skilful efforts of the practi- 
tioner ! In cases of this class, the loss of voice 
is owing to irregular distribution of the nervous 
influence. This again is caused by general irrita- 
bility, or susceptibility, of the whole nervous sys- 
tem ; or, in other words, by " the hysterical tem- 
perament." We shall seek in vain to restore the 
voice until we have removed that hysterical dia- 
thesis on which the loss of it depends. 

Cure. — When the disease has not arisen from 
a cause which contra-indicated emetics, we have 
generally begun with one ; and the following is 
what we have commonly employed, repeating it 
at intervals of three or four days, and adding to 
it, where the patient was robust, from gr. ss. to 
gr. i. of tartarised antimony: 

R Vini Ipecacuanha? f.gix. 
Oxymellis Scillre f.giii. M. 
The success that has attended its exhibition has 
been most conspicuous. 

Where the disease has appeared symptomatic 
of catarrh, we have followed up the emetic by 
saline, demulcent, and expectorant medicines. 
Leeches, but more especially blisters, to the fore 
part of the throat, have had an excellent effect. 

Where aphonia seems premonitory of apoplexy, 
the most prompt and effectual depletion by blood- 
letting, cupping, and purgatives, must be resorted 
to. Where, on the other hand, it is the conse- 
quence of apoplexy, we have chiefly relied on 
supping inter scapulas, leeches to the temples, a 
blister to the head, and, above all, a seton in the 
nape of the neck. 

When aphonia is symptomatic of hysteria (as 
it so often is), the constitutional treatment adapted 
to the latter must be had recourse to. We would 
advise the following formula?, which we have 



proved by experience to be well adapted to this 
and many other varieties of hysterical disorder : 
K Fcrri Sobcarbonatis ^i. ad ,~ss. 

Valeriana? Pulveris gr. x. M. fiat pulyis tei 
die sumendus. Or the following pills and mixture 
may be prescribed : 

B. Pilula? Galbani Comp. 
Pyrethri pulveris, da ,~i. 
Olei Anisi guttas vi. M. tcre simul optime, 
ct divide in pilulas xxiv. quarum sumat ii. vcl iii. 
omni nocte. 

Necnon, R Sulphatis Ferri g. ii. 
Acidi Sulphuric. Dil. M. x. 

Solve, et adde 
Infusi Gentians Comp. f.3ix. 
Aqua? Cinnamomi f.^iii. 
Sulphatis Magnesia?, ^i. M. fiat haustus 
bis quotidie sumendus. 

With the above plan, the shower-bath every 
morning, at first tepid and then cold, (with or 
without the addition of salt to the water.) may be 
conjoined, and should he persevered in for several 
weeks. 

It is not unworthy of remark that, in one case 
of this disease, which had existed long, and re- 
sisted a great variety of remedies, wc were fortu- 
nate enough to effect a cure by half-drachm doses 
of balsamum copaiba:, given three times a day, 
rubbed up with mucilage of gum arabic and pep- 
permint or cinnamon water. 

A. Robertson. 

APHTHjE, (from the Greek a-nra, accendo,\a 
inflame,} is the term employed to denote those 
numerous white specks, or curd-like vesicles, that 
not unfrequently appear on the tongue and palate, 
and gradually diffuse themselves all over the inside 
of the mouth and fauces. They ought to be con- 
sidered inflammatory exudations rather than ul- 
cers; for they are not surrounded by any redness; 
and, when they alternately fall off and re-appear 
in successive crops, (as they are apt to do.) we 
find the cuticle abraded underneath, and the parts 
excessively tender and smarting, but the cutis vera 
unbroken. 

Three varieties are enumerated by Dr. Mason 
Good and other modern writers ; viz. 1. aphtha 
infantum; 2. aphtha maligna; and, 3. aphtha 
chronica. 

Dr. Cullen has placed this disease in the class 
Pyrexia?, and order Exanthemata ,- but his collo- 
cation and definition apply more particularly to 
the aphtha? infantum, or milk-thrush ,• which is 
the only variety that can be really or generally 
considered idiopathic. The others are purely 
symptomatic, and are chiefly of importance from 
their indicafiiig a reduced state of the vis vita?, and 
an impoverished condition of the blood. 

We have witnessed the appearance of the 
symptomatic varieties in a great many acute dis- 
eases. In cases of enteritis ; in bilious, remittent, 
typhoid, and petechial fevers ; in hectic fever, 
from confirmed pulmonary disease, or from the 
suppuration of psoas abscess in that irritable con- 
dition of the alimentary canal denoted by fever, 
vomiting and purging of bilious or other acrid 
matters ; in the febris lenta attending diabetes, 
atrophy, &c. ; in the fever accompanying slough- 



APHTHA 



141 



ing wounds or scorbutic ulcers ; in short, in vari- 
ous states of great constitutional irritation and 
prostration we have found aphtha? to supervene. 
They arc always to be looked upon as a most un- 
favourable symptom; not from any mischief in- 
herent in themselves, or caused by them, but from 
their indicating general exhaustion and prostration 
of the system. 

We have known, however, very many acute 
cases terminate favourably, notwithstanding the 
occurrence of aphthae during their progress ; and, 
indeed, so long as the aphthous specks retain their 
purely-white colour, little danger need be appre- 
hended. But when the early crops fall off and 
are succeeded by others, at first yellow in their 
hue, and gradually degenerating into brown or 
black, they may be looked upon as almost infalli- 
ble tokens of a fatal issue to the concomitant dis- 
ease, whatever that disease may be. 

In such disastrous circumstances the aphthae 
pervade the whole alimentary canal. Indeed some 
authors of reputation contend, from the cardialgia, 
singultus, acid eructations, and gripings that usu- 
ally precede or accompany them, that they always 
originate in the stomach, even before they mani- 
fest themselves in the mouth and fauces. Be this 
as it may, it is unquestionable that in all cases 
where aphthae show themselves, they are preceded 
by evident acrimony in the stomach and duode- 
num. 

The treatment, under such a state of things, 
ou^ht obviously to be directed rather to the con- 
comitant disease than to the aphthous condition 
of the mouth and throat. But as the latter is 
often productive of great distress in swallowing 
either nourishment or medicine, gargles and other 
topical detergents must not be neglected. We 
have experienced beneficial effects, in some severe 
cases, from pencilling the inside of the mouth 
with a solution of argentum nitratum, in the pro- 
portion of ^ss, or even h)ii, t° an ounce of water. 
Gargles also of sage-tea, or of simple infusum 
rosse, are often useful. One drachm of alum to 
a pint of infusion of red rose-leaves frequently 
has a good effect in cleansing the mouth. But, 
upon the whole, the most soothing application we 
have yet found is the following : — 

R Sodae boratis gi. ad ^ii. 
Aquae 1.3 vii. 
Mellis rosae f.^vii. 

Tinct. Opii f.ji. M. fiat gargarisma. 
Frequent sips of this are to be taken, and held in 
the mouth for four or five minutes at a time, and 
afterwards discharged. 

The aphtha infinitum usua'ly attacks those 
children that are brought up by hand, rather than 
such as live entirely on the breast. In such cases 
the exciting cause is the food not being properly 
digested, but becoming acid and acrimonious ii» 
the fir*t passages. 

The first step in the treatment is well to evacu- 
ate the primffi viae by castor-oil, magnesia and 
rhubarb, or manna dissolved in warm milk. Our 
next measures must be to obtund acrimony, and 
excite perspiration. These purposes will be best 
accomplished by the warm bath, particularly 
where there is much febrile beat, or where the 
child is tetchy and restless ; and also by f.^ss of 
mistura cretas with M. v. of vinura ipecacuanhas, 



given every four hours. We would recommend 
the following formulas : 
R Cretae preparatae £)ii. 

Mucilaginis acaciae f.gss. Tere simul, et 
adde aquae f.^iss. 

Liquor, ammon. acetat. f.^vi. 

Spir. aether, nitric, f.^iss. 

Vini antimonii f.^ss. M. 
The dose a table-spoonful every four hours. 

With infants who cannot employ a gargle, a 
linctus, consisting of gi of borax (sub-boratc of 
soda), rubbed up in one ounce of mel rosae, and 
applied frequently to the mouth and fauces by 
means of a feather, or a camel-hair pencil, is often 
a useful succedaneum. 

Where the aphthae put on a dark or sloughing 
appearance, the sulphate of quinine dissolved in 
the infusion of roses, or the decoction of bark 
acidulated with muriatic or dilute sulphuric acid, 
must be resorted to in doses adapted to the age 
and other circumstances of the patient. Port- 
wine or brandy must also be exhibited. Gargles 
and the inhalation of the vapour of warm water 
and vinegar, must likewise be employed. Of all to- 
pical applications, however, the most powerfully 
antiseptic we are acquainted with is the following : 
R Liquoris sodas chlorinatse, tincture myrrhae 
da f.^ss. Aquae f.,5vi. Aquse rosae f.^i. M. fiat 
gargarisma saepissime adhibendum. 

A. Robertson. 

[There appears to be a marked difference be- 
tween the pultaceous inflammation of the mouth, 
that constitutes Aphthae, Infantum, and the folli- 
cular inflammation that constitutes Aphthse Adul- 
torum. The latter — aphthous stomatitis — is 
seated chiefly in the follicles of the mucous 
membrane of the mouth ; hence the name folli- 
cular stomatitis, given to it by some. When 
the membrane is inspected at an early period of 
the disease, it presents the appearance of simple 
stomatitis; and afterwards, small transparent, grey- 
ish or whitish vesicles are perceptible, and at the 
base of each vesicle there is a raised ring, which 
is resisting, and of a white colour. Subsequently 
the vesicle gives way at the top, and allows the 
fluid to escape from it ; after which it becomes 
transformed into an ulcer, which spreads, and is 
bounded by a red circle, — the raised border that 
occupied or surrounded the base of the vesicle 
gradually disappearing. Cicatrization succeeds. — 
at times rapidly, but at others gradually, — whilst 
at others, again, it is exceedingly tardy, and the 
ulceration is very apt to recur after it has once 
healed. Cases very difficult of management are 
occasionally seen in nursing- women; and.whai is 
singular, they would seem to occur more frequently 
in certain localities than in others, owing to causes 
that have not yet been appreciated. The stomati- 
tis of nurses is not, however, peculiar to this coun- 
try, as has been" imagined by some. 

The treatment of the aphthffi of the adult must 
be regulated greatly by the concomitant condition. 
In the first instance, mucilaginous, and, afterwards, 
gently astringent collutories may be prescribed ; 
and, where the ulcerations are not numerous, they 
may be treated with solid nitrate of silver, sulphate 
of copper, or tincture of iodine. If inflammatory 
symptoms accompany them, the constitutional 



142 



APOPLEXY, (CEREBRAL) 



phenomena must be met by appropriate remedies. 
Often the affection is manifestly adynamic, and 
requires the use of tonics, as the cold infusion of 
cinchona ; and very obstinate cases require the 
thorough revulsion which travelling air and exer- 
cise are capable of effecting. 'With the same view, 
the various eutrophics may be needed which are 
prescribed in other cases of faulty nutritive action 
of the dermoid tissues. (Practice of Medicine, 
2d edit. p. 32 : Philad. 1844.) 

ROBLEY DUNGLISON.] 

APOPLEXY Cf.bf.bbat, Apoplexy (from 

the Greek word a-oTz\>)aaw, to strike) has been 
defined, loss of sensation, voluntary motion, and 
intellect or thought ; respiration, and the action 
of the heart and general vascular system, being 
continued. The disease has been so termed from 
the suddenness and violence of the attack in many 
instances ; and, for the same reason, the patient is 
said to be attonitus (thunder-struck), or sideratus 
(planet-struck) ; as if the disease were of un- 
earthly origin. 

It is liable to be confounded with syncope or 
fainting, and with natural sleep ; from both of 
which, for the purposes of practice, it requires to 
be distinguished. In syncope, respiration is sus- 
pended, the pulse is not to be felt at the wrist, the 
features shrink, and the surface of the body turns 
pale and cold. In apoplexy, the reverse of all 
these takes place. It is less easy to discriminate 
between apoplexy and natural sleep : the distinc- 
tion can only be made, indeed, by our being able 
to rouse the person from sleep, however profound, 
by a certain degree of irritation : this cannot be 
done, or but very imperfectly, in apoplexy. The 
suddenness and violence with which apoplexy 
often makes its.attack ; the total loss of conscious- 
ness, of feeling, and of voluntary movement that 
attends it; and the not unfrequently fatal termi- 
nation of the disease, are circamstances well cal- 
culated to attract, as they have actually attracted, 
the attention of physicians from a very early pe- 
tiod. We find it accordingly described by the 
Greek and Roman writers, and their successors of 
the Arabian school, with a minuteness and accu- 
racy that have hardly been exceeded in modern 
times. Little, however, is to be found regarding 
its intrinsic nature till within a comparatively late 
] eriod ; and even at present the pathology of the 
disease is far from being satisfactorily settled, if 
we may judge from the various and contradictory 
opinions that have been entertained on the subject. 

General description. — There is great diversity 
in the mode of attack of apoplexy, as well as in 
the greater or less severity of its symptoms. 
Sometimes the attack is nearly instantaneous and 
complete ; the patient, previously in apparent 
health, falling down insensible, with an immediate 
abolition of all the sensorial functions. On other 
occasions the approach of the stroke is felt by the 
patient ; he puts his hand to his head, or makes 
an alarming exclamation of something unusual 
felt in the head ; and then falls down insensible. 
In most cases, (and probably it would be found so 
in all. if sufficient attention were paid.) the attack 
is preceded, for a longer or shorter period, by pain 
Mi the head, or by more or less of disorder in the 
■ervsorial functions ; such as tinnitus aurium, im- 



perfect vision, numbness or a sense of pricking in 
the extremities, giddiness, imperfect articulation, 
loss of memory, drowsiness, or nightmare. The 
degree in which the sensorial functions are im- 
paired in apoplexy is also various. In the more 
severe cases, sensation, voluntary motion, and in- 
tellect, are all entirely abolished. In slighter 
affections, the patient retains some degree of con- 
sciousness, is sensible to impressions, and capable, 
to a certain extent, of voluntary movement. The 
pupils of the eyes are variously affected at differ- 
ent times. Although, in many cases, they are 
observed to be largely and equally dilated, and in- 
sensible to the impression of light, there arc still 
more in which they are in a contracted state, 
though often unequally in respect of each other. 
Sometimes they contract and dilate alternately 
with great quickness, without being influenced by 
the stimulus of light. Sometimes one side of the 
body lies motionless, without manifesting the least 
degree of feeling, even when strongly irritated; 
while convulsive movements, with perhaps some 
degree of feeling, are perceived on the opposite 
side. We are then enabled to predict that, in case 
of recovery from the apoplectic state, hemiplegia 
will be left behind. The disease consisting essen- 
tially, as will be shown hereafter, in a suspension, 
more or less perfect, of the sensorial or proper 
functions of the encephalon, other functions are 
not necessarily deranged ; nor when they are so, 
is it in any uniform way. Respiration, in violent 
cases of apoplexy, is commonly slow and labori- 
ous, the patient snoring loudly as in deep sleep. 
At other times the breathing is natural. The 
general circulation of the blood, as indicated by 
the pulse at the wrist, is equally various in apo- 
plexy. Sometimes the pulse is slow, full, and 
bounding; with flushing and fullness of the face, 
and heat of the extremities : at other times the 
pulse is small and weak, or perhaps irregular .■ 
while the face is pale, the features are shrunk, and 
the extremities cold. In extreme cases, such as 
are likely to prove almost immediately fatal, the 
pulse from the beginning is imperceptible, or 
nearly so; the heart appearing to be paralyzed, as 
well as the voluntary muscles. In such c:ises 
death quickly ensues. The alimentary canal is 
also variously affected in apoplexy. In some 
cases, the power of swallowing is lost or impaired; 
and in such it is hazardous to administer any thing 
by the mouth, as being likely to induce suffocation, 
or at least to excite violent cough, which is not 
without danger to the patient. In numerous in- 
stances apoplexy is ushered in by vomiting ; the 
disease then is often referred to a disordered state 
of the stomach, as the primary cause ; but gener- 
ally without reason, the disorder of stomach being 
mostly secondary, and dependent upon the brain. 
The mistake is important, as leading to the em- 
ployment of emetics, the use of which is not un- 
attended with danger. The bowels are commonly 
torpid in apoplectic cases. Sometimes, however, 
the urine and faiccs escape involuntarily. This 
marks a state of disease which generally proves 
fatal. Profuse sweating is also among the most 
unfavourable signs. 

Apoplexy may last but for a short time, as a few 
minutes, and then entirely disappear ; or it may 
prove fatal immediately, or after the lapse of a few 



APOPLEXY, (CEREBRAL) 



143 



hours i it may even continue for several days, and 
then prove fatal. In a considerable number of 
instances it ends In hemiplegia, consciousness re- 
turning, while voluntary motion, and sometimes 
sensation, are lost. Palsy has thus been called a 
minor degree of apoplexy. Hemiplegia may take 
place in very different degrees : the entire half of 
the body sometimes sutlers, the medial line being 
marked with great accuracy ; so that one half the 
tongue only, with its muscles, is paralyzed. Or 
the affection may be confined to the face, or to a 
single limb. The approach of apoplexy is some- 
times denoted by merely a loss of feeling in one 
or more of the fingers. 

In some cases of hemiplegia, the sensibility of 
the part remains, or is even morbidly increased ; 
while the voluntary muscles are alone paralyzed. 
In higher degrees of the disease, both the blood-ves- 
sels and the absorbents appear to partake of the 
paralysis, if we may judge from the weaker state 
of the pulse, as compared with that on the sound 
side, and also from the oedematous state of the 
limb ; which seems to show deficient absorption. 

In all cases of apoplexy there is a disposition 
to a recurrence of the disease ; the number of fits 
and the period of recurrence being uncertain. In 
most cases the patient is sooner or later destroyed. 
Many persons survive a considerable number of 
slight attacks, but the more severe commonly 
prove fatal on the second or third occasion ; thus 
verifying, in some degree, the popular remark, 
that the third fit of apoplexy always kills the pa- 
tient. 

Apoplexy may take place at any age, but is 
comparatively rare at the early periods of life ; and 
when it does occur in the young, it usually comes 
on slowly, and not by a sudden stroke, as at a 
more advanced age. A great proportion of old 
people, are cut off by apoplexy. The form of 
body appears to give a predisposition to the dis- 
ease, as a large head, short neck, and corpulency 
of habit. Luxurious diet, excess in drinking, pro- 
longed study, and intense thinking, are all circum- 
stances giving predisposition to the disease. Apo- 
plexy is of more frequent occurrence in men than 
in women ; probably from the former being more 
addicted to excesses, both as regards body and 
mind. 

Morbid appearances. — It is reasonable to ex- 
pect that the intrinsic nature of apoplexy might 
be determined by a careful examination, after 
death, of the organ principally affected. This, 
however, as will be presently seen, is true to a 
certain extent only ; for there are numerous in- 
stances on record of apoplexy proving fatal, 
where no change in the structure or condition of 
the brain could be detected, that was at all ade- 
quate to explain the symptoms of the disease, or 
to account for the death of the patient. And 
even where manifest changes have been observed, 
they have been so various, and of so common a 
description, as to afford no complete or satisfactory 
elucidation of the subject. 

Many of the morbid appearances mentioned by 
writers as having been observed in the brain of 
persons who have died of apoplexy, are by no 
means to be considered as the immediate cause of 
the apoplectic state, since similar appearances are 
found in o'her kinds of cerebral disease, while 



they are not invariably met with in apoplexy 
itself. The morbid appearances to which we al- 
lude are, malformations of the cranium, ossifica- 
tion of the membranes or blood-vessels, adhesion 
of the membranes, false membranes, alteration in 
the texture of the brain, i. e. unusual hardness or 
softness, tumours, hydatids, concretions of various 
kinds, &c. On the other hand, cases of apo- 
plexy have been recorded in which the apoplectic 
seizure has proved fatal without leaving any dis- 
coverable lesion in the brain, though the symp- 
toms were well marked before death. To these 
cases, which are certainly uncommon, Dr. Aber- 
crombie has proposed to apply the term simple 
apoplexy. 

[It is also termed nervous apoplexy. The 
attack is almost always sudden, and immediately 
succeeding some powerful mental emotion. Should 
the symptoms of apoplexy have occurred many 
times ; have continued for a short period only, 
and left behind them no evidence of modified con- 
dition of the encephalic neutine, it has been in- 
ferred that the apoplexy is of this variety. This 
inference might, however, be very erroneous, 
inasmuch as all the functional phenomena of 
apoplexy may be developed under a hyper&'mic 
condition of the vessels of the encephalon, which 
may soon pass away.] 

The morbid changes in the brain generally ob- 
served after death, which really appear to give 
rise to the apoplectic state, are the following : — 

1. Extravasation of blond. — This is generally 
a fatal termination of apoplexy, and may be sus- 
pected, if not positively predicted, when the attack 
occurs suddenly and unexpectedly, the patient be- 
coming at once motionless and insensible, to 
which condition convulsions sometimes succeed. 
In other instances the individual docs not become 
instantly insensible, but complains only of unea- 
siness or fixed pain in the head, often confined to 
one side. He may remain sensible for some time 
after the attack of head-ach ; more or less oppres- 
sion, however, succeeds, till perfect coma is esta- 
blished, from which recovery never takes place. 
The blood in those cases is found extravasated 
most commonly in the substance of the brain in 
cavities of different sizes ; sometimes there is a 
communication between the cavity thus formed 
and the ventricles, or the blood finding its way 
through a lacerated opening to the surface, becomes 
extravasated under the arachnoid membrane. 
When the blood has been effused in one hemi- 
sphere of the brain, palsy of the opposite side has 
been observed before death. The appearance of 
the extravasated blood varies according to the 
duration of the disease. When the apoplexy has 
proved suddenly fatal, the blood is dark-coloured, 
almost fluid, or in soft semi-liquid masses. If the 
patient survives for a longer period, the coagulum 
acquires a greater degree of consistency, and is of 
a pale red and sometimes dark yellow colour. 
The substance of the brain surrounding these apo 
plectic cysts becomes altered : it generally appears 
injected, ami acquires a greater degree of softness ; 
this softened state does not extend deep, but be 
comes gradually less and less perceptible, till it i* 
impossible to discover any difference between the 
sound and diseased portion of the brain. The 
quantity of blood which is thus cxtravasa'ed n 



APOPLEXY, (CEREBRAL) 



.44 

very various : in some cases it does not exceed a 
few drops — often, however, two, four, or six ounces 
Lave been found in these cysts. 

Extravasation of blood, nevertheless, is not al- 
ways fetal, as appears from the changes observed 
in the brain of persons who have survived the 
apoplectic attack, but remained paralytic, with 
more or less disturbance in the sensorial powers. 
In such cases the blood which has become effused 
is partially or in some instances entirely absorbed, 
and the parietes of the cyst undergo a reparative 
process — a partial cicatrization ; they approximate 
and become slightly connected by soft intersecting 
bands, so as to form little cavities, which some- 
times contain a fluid of various quality and ap- 
pearance. The number of these old apoplectic 
cysts corresponds with the sanguineous effusions 
which have at different times taken place, and 
therefore several have been found in the same 
brain. In some rare instances these apoplectic 
cysts have been found completely cicatrized, 
which shows how much is often effected by the 
reparative powers of the system itself. With re- 
gard to the source of the hemorrhagic effusion, in 
apoplexy, it appears from the researches of M. 
Serres that the blood may in some cases proceed 
from the minute vessels of the brain without rup- 
ture, constituting that form of the disease to 
which the French writers have applied the term 
meningeal apoplexy : in these cases the blood es- 
capes from the vessels of the arachnoid into the 
subjacent delicate cellular tissue, or into the ca- 
vity of the ventricles ; and the substance of the 
brain is sound. When blood is found in the ven- 
tricles, it may proceed from this source, or from 
the vessels of the choroid plexus, or from a com- 
munication with an apoplectic cyst in the sub- 
stance of the brain. 

The hemorrhage, however, most usually takes 
place from rupture of the blood-vessels :* in el- 
derly persons the arteries of the brain often become 
diseased from ossification ; hence, when the blood 
is impelled with more than ordinary force, they 
are liable to give way, especially at those periods 
of life, when the solids in general lose their firm- 
ness. — " Omnes rami carotidis," says Haller, " qui 
cranio continentur, tenui, solida,, fra^ili magis, 
quam reliquns arteries, substantia sunt." — Halleri 
prim, lin, § 337. Sometimes the blood issues 
from a congeries of these small arteries, occasion- 
ally from an artery of considerable size. Thus 
M. Serres traced in one instance the source of the 
hemorrhage to rupture of the communicating 
artery of Willis. In another individual it took 
place from aneurismal disease and rupture of 
the basilar artery. In one case, reported by M. 
Moulin, of apoplexy which proved suddenly fatal, 
six ounces of dark-coloured blood were found in 
the centre of the cerebellum, which had arisen 
from rupture of the trunk of the inferior cerebellar 
arteries. It would appear that, in all these cases, 
the morbid condition of the arteries constitutes the 
principal and primary lesion. In the sixth vo- 



lume of the Edinburgh Medical Essays, a case 13 
-riven by Dr. Douglas, in which the left lateral 
sinus was ruptured ; and a very uncommon case 
(quoted by Abercrombie) is recorded 111 the Me- 
dical and 'Surgical Register of the Hospital of 
New York, of a man who was suddenly seized 
with hemiplegia of the right side, and died five 
days afterwards. On examination ot the brain, 
blood was found between the dura mater and 
bone, which was traced to erosion of a vessel from 
caries of the inner surface of the parietal bone of 
the left side, not larger than a sixpence. 

The most frequent seat of extravasations of 
blood in apoplexy, according to Morgagni, is the 
corpus striatum. This opinion has been found 
substantially correct by modern writers. Of 
twenty-eight cases examined by Rochoux, in 
twenty-four the extravasation was found in the 
corpus striatum. 

[Of 386 cases, recorded by M. Andral, the 
extravasation was seated in the part of the cerebral 
hemispheres, situate on a level with the corpora 
striata and the optic thalami, and at the same time 

in both those bodies, in 202 cases 

In the corpora striata, in 61 " 

In the optic thalami, in 35 " 

In the portion of the hemispheres 
above the centrum ovale of Vieus- 



sens, in 



27 



In the lateral lobes of the cerebellum, in 16 

Anterior to the corpora striata, in. . . 10 

In the mesocephalon, in 9 

In the spinal marrow, in 8 

Behind the optic thalami, posterior 

lobes, in 7 

In the median lobe of the cerebel- 
lum, in ° 

In the peduncles of the brain, in . . . 3 

In one peduncle of the cerebellum, in 1 

In the corpora olivaria, in 1 

In the pituitary gland, in 1 

In the central white parts, in 



* I I'lus is not in accordance with the investiga- 
tions of pathologists. On the contrary, the appear 
anccs cm dissection favour the viewthat the. hemorrhage 
generally occur* from transudation through the parietes 
of the vessels, which in many cases are softened shunt- 
'aneously with or subsequent to the ramollissernent of 
ihe encephalic neurine.'J 



386] 

Morgagni thought that the blood was more fre- 
quently effused on the right than on the left side 
of the brain. This, however, does not accord 
with the experience of Rochoux, who found, that 
of forty-one cases, examined after death, in eighteen 
the extravasation was in the left hemisphere ; in 
seventeen on the right side, and in six it had 
taken place in both hemispheres. 

2. Serous effusion. — When serous fluid is ac- 
cumulated largely in the brain, so as to occasion 
apoplexy by pressure, the chief seat of the fluid is 
the different ventricles ; though more or less is 
generally found every where between the mem- 
branes, often passing down the spinal column. 
Apoplexy may be suspected to depend upon this 
this cause, when the symptoms of oppressed brain 
come on slowly, and in an imperfect degree, 
without any thing like a sudden stroke or fit. In 
many of these cases, however, of whit is termed 
serous apoplexy, a sudden and more violent attack 
succeeds, so as to prove quickly fatal ; and in 
such cases blood as well as serum is often found 
effused in the brain after death. Hence it is ob- 
vious that no ahsolute line of distinction can be 
drawn between serous and sanguineous apoplexy i 



APOPLEXY, (CEREBRAL) 



145 



nor are they to be distinguished with certainty by 
symptoms during life. 

Serous apoplexy has been too generally sup- 
posed to be the only form of the disease to which 
persons of a spare infirm habit, with pale counte- 
nance and feeble pulse, are liable. This, how- 
ever, is a very erroneous idea. In many cases 
which have presented, during life, all the symp- 
toms and characters which have been usually re- 
garded as pathognomonic of serous apoplexy, ex- 
travasation of blood has been discovered on dis- 
section. Again, in fatal cases of apoplexy, in 
which serous effusion has constituted the only 
morbid appearance discovered, all the symptoms 
of sanguineous apoplexy have been observed 
during life, so that the only legitimate conclusion 
is, that the effusion is the effect of the previous 
vascular disturbance in the brain, and analogous 
to the dropsical effusion which often occurs after 
inflammation of serous membranes. It is equally 
apparent that the effusion is not the cause of the 
apoplectic symptoms, — these are produced by the 
morbid condition of the brain on which the effu- 
sion depends. 

The cerebellum being seldom affected in apo- 
plexy, (the disease being for the most part confin- 
ed to the cerebrum,) accounts sufficiently for the 
continuance of the action of the heart, and of 
respiration during the fit; these functions being 
more immediately dependent upon this part of the 
nervous system. [This view is not sustained by 
the observations of modern physiologists. The 
action of the heart is certainly not more immedi- 
ately dependent upon the cerebellum ; whilst the 
medulla oblongata would seem to be the nervous 
centre of respiration.] For the same reason, other 
functions dependent upon the general circulation 
often go on unimpaired ; as secretions of various 
kinds, and the evolution of animal heat. 

In many cases an unusual degree of tumes- 
cence of the veins upon the surface of the brain 
has been observed. This appearance has furnish- 
ed the grounds of the doctrine of venous conges- 
tion, of which so much use has been made of late, 
in attempts to explain the nature of apoplexy. 
But there is a fallacy here, which renders such an 
explanation very unsatisfactory, as will hereafter 
be shown. 

Causes of Apoplexy. — These have been di- 
vided into external or obvious, and internal, or 
such as can only be discovered by dissection after 
death. It is, however, necessary to observe that 
many cases are recorded of apoplexy taking place 
without any apparent external cause, while no 
internal cause, sufficient to account for the pro- 
duction of the disease, could be detected after 
death. 

The obvious external causes of apoplexy are 
the following : 

1. Causes acting mechanically, by making 
pressure on the brain : such are, fracture of the 
skull with depression of a portion of bone ; or 
blood extravasated immediately beneath the frac- 
tured bone, without depression. The reality of 
this cause is shown by the effect of direct pressure 
made upon the surface of the brain by the point 
of the finger, in cases where a portion of the skull 
has been removed by the trepan ; or on the fonta- 
nelle or opening between the cranial bones in the 

Vol. I.— 19 » 



head of infants. Some nations are said to destroy 
their supernumerary offspring in this manner. 

2. Causes tending to increase the arterial action 
of the brain ; either by direct application to the 
head itself, or, indirectly, through the medium of 
other organs. Of the former kind are, insolation, 
or exposure of the naked head to the mid-day 
sun ; and erysipelas affecting the scalp. The in- 
direct causes of vascular excitement of the brain 
are various : — external heat applied extensively to 
the skin, either through the medium of the sur- 
rounding air, or by means of the hot bath ; breath- 
ing a heated atmosphere, especially in crowded 
rooms, the effect being probably increased by 
breathing contaminated air; the inhalation of car- 
bonic acid gas, and probably of other mephitic 
airs ; violent exercise ; certain emotions of mind, 
as anger, terror, or joy ; indulgence in the plea- 
sures of the table, intoxicating drinks, opium, and 
other drugs of the narcotic tribe. Violent con- 
cussion of the brain, occasioned by blows or falls, 
induces a suspension of the sensorial functions, 
or an apoplectic state. This suspension of func- 
tions may be momentary, or it may be more dura- 
ble ; even life itself may be instantly extinguished 
in this way, according to the violence of the shock 
sustained. 

3. Causes which operate by impeding the re- 
turn of blood from the brain ; as stooping ; the 
application of a tight ligature round the neck, so 
as to compress the internal jugular veins ; tu- 
mours of any kind so situated in the neck or chest, 
as to interrupt the return of blood from the brain 
to the heart ; diseases of the heart or lungs imped- 
ing the transmission of the blood through the pul- 
monary vessels ; or a voluntary suspension of 
breathing after a full inspiration ; as in blowing 
wind-instruments, or in making great muscular 
efforts of any kind. 

The internal causes of apoplexy, or those that 
are only discoverable after death, are — extravasa- 
tion of blood in the substance of the brain or in 
the ventricles, or serous accumulations in any of 
the cavities, or between its membranes ; tumours 
of any kind, within the skull, of magnitude suffi- 
cient to press considerably upon the brain. Among 
the occasional causes of apoplexy also may be 
mentioned some forms of fever, and all the other 
forms of cerebral inflammation. Epilepsy and 
hysteria, likewise, often terminate their paroxysms 
by stupor, or an apoplectic state ; which in gene- 
ral disappears after a few hours, though it some- 
times ends fatally. Extreme cold, long continued, 
induces a state resembling apoplexy, as far as> re- 
gards the suspension of the primary functions of 
the brain. 

How these different causes, at once so numer- 
ous and apparently dissimilar in nature, operate 
so as to produce the apoplectic state, is an inquiry 
of some difficulty. It is, however, one of much 
practical importance, as the rational, and probably 
the most successful treatment of the disease will 
depend greatly upon a knowledge of the particular 
cause, and its mode of acting. These will be 
more fully considered hereafter. 

Theory of Apoplexy. — There are two points 
here to be determined, or at least to be inquired 
into, namely, the primary and essential seat of thp 
disease, and the intrinsic nature of the affection 



146 



APOPLEXY, (CEREBRAL) 



Willi respect to the for ner, there is little difficulty. 
When we consider attentively the essential char- 
acters of apoplexy, — that they all refer themselves 
to the brain, and consist in a suspension or inter- 
vuption of the sensorial or proper functions of this 
organ, it would seem impossible to refer them to 
any other source. Some, however, have looked 
to the stomach as the primary seat of apoplexy, 
at least in those cases where the attack supervenes 
upon a full meal, or is ushered in by vomiting. 
The notion that a distended state of stomach acts 
by compressing the descending aorta, and thereby 
determining a larger flow of blood to the brain, is 
too mechanical to be probable. Were this a sat- 
isfactory explanation, it would be an easy matter 
to produce apoplexy at any time, by even mode- 
rate pressure at the pit of the stomach. An easier 
explanation may be given. The stimulus of a 
hearty meal, aided, as it commonly is, by strong 
drink and mental excitement, has been sometimes 
followed by, or it may be said, has given rise to, 
a fit of apoplexy ; but it is by exciting the vascu- 
lar action of the brain that such a cause operates. 
The brain is still the part from the affection of 
which the apoplectic state arises ; the stomach is 
merely the medium through which the brain is 
impressed. As to to the fact of many cases being 
ushered in by vomiting, thus affording, it was 
imagined, a proof that the stomach is primarily 
concerned, it is rather taking the effect for the 
cause. The same observation applies to the lungs. 
When the lungs are so diseased as to be unable 
to transmit the blood through them with sufficient 
freedom, the vital fluid will be deficient in those 
properties which it derives from the atmosphere in 
respiration, and by which it is fitted to maintain 
the living actions. In this state, it may, no doubt, 
contribute to the production of that general torpor 
of system which is so evident in such cases. But 
much more is attributable to the mechanical im- 
pediment afforded to the return of blood from the 
brain, by which the cerebral circulation is inter- 
rupted, and the functions of the organ thereby 
suspended or annihilated : apoplexy, therefore, is 
always and essentially a brain affection. 

The determination of the second point of the 
theory, viz., the actual condition of the organ 
affected — the brain — in other words, the proxi- 
mate or immediate cause of the symptoms, is a 
matter of greater difficulty, and about which a 
variety of opinions have been entertained ; few 
of which, however, are deserving of serious no- 
tice. Among these may be mentioned the notion 
that the symptoms are caused by a morbid state 
of the animal spirits, — by fermentation or ebulli- 
tion of the blood, — by a relaxation of the nerves, 
— by spasm of the meninges or membranes cover- 
ing the brain, — or by spasm of the nerves and 
"essels of the brain, — (hence the term nervous 
apoplexy, still employed by some to designate 
those instances of the disease in which no morbid 
change is discoverable after death.) It is hardly 
necessarv to observe that these notions are purely 
hypotnetical, and rest upon no sort of foundation ; 
and much more cannot be said, it may be feared, 
in favour of the opinion of Dr. Cullen, that cer- 
tain of the causes of apoplexy operate by induc- 
ing an immobility of the nervous fluid. Other 
immediate causes of the apoplectic, state have 



been assigned ; as compression of the cerebral sub- 
stance, and venous congestion; both of which, 
however, are liable to insuperable objections, as 
will appear upon a fuller investigation hereafter. 
With much greater probability may the symptoms 
of apoplexy be referred to impeded or interrupted 
circulation in the brain, a state which most, if not 
all, of the known and obvious causes of the dis- 
ease have a manifest tendency to produce, and 
which seems fully adequate to the production of 
the effect, namely, a suspension of the sensorial 
functions. When it is added that the treatment 
of the disease will very materially turn upon the 
admission or disproval of this opinion, it will bo 
readily allowed to be deserving of minute investi- 
gation. 

The nature of apoplexy in general, however, 
cannot be understood, nor its most essential symp- 
toms explained, nor the operation of its causes 
made intelligible, without adverting to certain 
physical peculiarities, by which the brain is dis- 
tinguished from other organs. These peculiarities 
are not now brought forward for the first time. 
They were long ago demonstrated by the eminent 
professor at Edinburgh, the late Dr. Monro, and 
have been recently confirmed by a variety of well- 
conducted experiments instituted on the subject 
by Kellie, Abercrombie, and others, who have 
drawn a number of important conclusions from 
the facts so established. These facts, as well as 
the inferences deducible from them, have been 
strangely neglected, and indeed have been scarcely 
at all referred to either theoretically or practically, 
by recent writers on diseases of the brain ; al- 
though it is quite impossible, without having re- 
course to them, to explain or even to comprehend 
a great number of the phenomena that attend 
such affections. 

The physical conditions, then, by which the 
brain is distinguished from other organs, are those 
which follow : 

1st. The brain is enclosed in an unyielding case 
of bone, the cranium or skull, the contents of 
which are by this construction excluded from the 
influence of atmospheric pressure. 

2dly. The cavity of the skull is always accu- 
rately tilled by its contents, namely, the encepha- 
Ion or general mass of brain, including the mem- 
branes, and vessels, and the blood contained with- 
in them. So long as the skull is perfect, there 
can be no rising and tailing of the brain, so as in 
the latter case to leave a vacuity between the skull 
and the surface of the brain, these parts being al- 
ways in actual and close contact. 

3dly, The contents of the skull solid as well, 
as fluid, if not absolutely incompressible, at least 
are so by any force that can by possibility be ap- 
plied to them during life ; and there is no air, or 
other elastic fluid, to be found within the cavity. 

This incompressibility of the cerebral substance 
is easily demonstrated by experiment. It is a 
property by no means belonging exclusively to the 
brain, more than to the whole of the animal solids. 
This is the less to be wondered at, when it is 
recollected how large the proportion of water is 
which enters into the composition of these, and 
that water, as well as other fluids, is so nearly 
incapable of compression as to require a vast force 
to render it at all perceptible. But although the 



APOPLEXY, (CEREBRAL) 



147 



substance of the brain, in common with other 
animal solids, be incompressible, its blood-vessels 
will readily yield to pressure, so as to be emptied 
of their contents; a necessary consequence of which 
is, a stoppage of the circulation in the part so 
affected. The pressure may be made to take place 
on any part of the brain, even the most remote 
from the principal vessels ; yet nevertheless the 
pressure, by operating through an incompressible 
substance, may influence vessels the most distant, 
so as thereby to impede, if not wholly interrupt, 
the cerebral circulation. 

The circumstances above stated with respect to 
the brain, lead to very important deductions, both 
theoretical and practical. It follows, ex necessitate 
rei, that no material variation can take place, 
within a short period, in regard to the absolute 
quantity of blood in the brain. No additional 
quantity can be admitted into the blood-vessels 
situated there, the cavity of the skull being already 
completely filled by its contents. A plethoric 
state of over-fulness of the cerebral vessels altoge- 
ther, though often talked of, can have no real 
existence ; nor on the other hand can the quan- 
tity of blood within the vessels of the brain be 
diminished, any more than can wine or other fluid 
be drawn from a cask without furnishing an 
equivalent for the portion abstracted from it, by 
the supply of an equal bulk of air, which in the 
case of the brain can of course find no entrance. 
No abstraction of blood therefore, whether it be 
from the arm or other part of the general system, 
or from the jugular veins, (and still less from the 
temporal arteries,) can have any effect on the 
blood-vessels of the brain, so as to lessen the 
absolute quantity of blood contained within them. 

From the experiments of Dr. Kellie, it was 
found that in animals bled to death the brain still 
contained the usual quantity of blood ; and in 
some cases the superficial veins were found gorged 
with blood, and the sinuses full ; the rest of the 
body being at the same time blanched, and drained 
of its blood. In a few instances, the brain appeared 
to contain less blood than usual ; but then there 
was found some serous exudation. When the 
cranium of the animals subjected to these experi- 
ments was perforated before they were bled, the 
brain was as much emptied of its blood as the rest 
of the body. In two instances of persons that had 
been hanged, the cellular membrane of the whole 
head externally was turgid with blood ; but 
nothing peculiar was observed in the state of the 
vessels of the brain itself. When blood is sud- 
denly or rapidly extravasated anywhere within the 
skull, the space thus occupied can only be fur- 
nished by the compression and consequent empty- 
ing of the blood-vessels in other parts of the brain ; 
and in the same degree that this happens, it is 
evident that the circulation of such parts must be 
interrupted. But in the formation of tumours 
within the skull, and during the slow accumula- 
tion of serum from inflammation or any other 
cause, the cerebral substance itself may be absorbed, 
to an extent corresponding with the bulk of the 
tumour, or the quantity of serum deposited. The 
circulation of the brain may then go on uninter- 
ruptedly, and thus the apoplectic symptoms be 
prevented. 

But although, under ordinary circumstances, the 



absolute quantity of blood contained within tho 
vessels of the brain must remain the same, there 
may be great differences in regard to its distribu- 
tion, and the force and velocity with which it is 
moved. Thus, the arteries of the brain altogether 
may be unusually distended with blood ; but in 
this case the veins will be in the same degree 
compressed and emptied, and the circulation of the 
organ proportionally interrupted, with a corre- 
sponding interruption of functions. 

Again, there may be a partial fulness or disten- 
sion of vessels in one part of the brain only, but 
this must be at the expense of the rest of the 
brain, which will be proportionally deprived of the 
usual supply of blood. This will be the case in 
circumscribed cerebral inflammation, as well as in 
other cases of partial excitement of the organ. 
The different parts of the brain will then be in 
different, and perhaps opposite states, in regard to 
the performance of their functions. The functions 
of one of the cerebral organs may be excited, 
while those of another may be imperfectly carried 
on or depressed. Such an inequality in the state 
of the cerebral functions is observable in most 
diseases of the brain ; for there are probably few 
in which the whole organ is simultaneously and 
equally affected. 

In like manner there may be great diversity 
with respect to the force and velocity of circula- 
tion in the brain ; the absolute quantity of blood 
in the vessels remaining still the same. In this 
way the functions may be more or less excited, or 
more or less disturbed. These changes in the 
state of the cerebral circulation are all independent 
of the heart, the action of which has but little 
influence over the brain or its functions. It fol- 
lows, from what has been now stated, that blood- 
letting, when employed as a remedy in apoplexy 
or other brain-affections, however useful it may be 
and undoubtedly is, in many cases, does not effect 
its purpose by diminishing in any degree the 
absolute quantity of blood in the brain, but by 
reducing the velocity and impetus of the circula- 
tion there, and which it does by influencing the 
general system. 

We have seen that the changes observed in the 
brain of apoplectic persons are very dissimilar; 
and that, in some instances, as has been stated 
above, no material deviation from the natural state 
of parts has been found ; it is plain, therefore, 
that such changes, when they do occur, cannot be 
the proximate cause, the causa continens, of the 
symptoms, but are to be considered, at most, as 
remote causes ; and, with regard to some of them, 
are to be looked upon rather as mere coincidences 
than causes. 

The opinion that appears to prevail most gene- 
rally at present, as to the immediate cause of the 
suspension of functions that constitutes the apo- 
plectic state, is that the remote causes of the dis- 
ease, such as extravasated blood, and accumulation 
of serum, produce a compression of the cerebral 
substance, thereby interrupting its functions. But, 
besides that some of the remote causes of apoplexy 
have no apparent tendency to make any direct 
pressure on the brain, it must not be overlooked 
that the cerebral substance being in its nature 
incompressible, cannot, so long as the blood is 
contained within its vessels, be exposed to greate> 



148 



APOPLEXY, (CEREBRAL) 



pressure at one time than another. It must be in 
some other way, therefore, than bv compression 
3f the substance of the brain, that the remote 
causes act in producing their effect. It cannot be 
questioned that pressure on the brain of any kind, 
if carried to a certain extent, is capable of inter- 
rupting the functions of the organ so as to induce 
apoplexy ; but there is good reason to believe that 
the pressure operates upon the blood-vessels, so as 
to impede mechanically the passage of the blood 
through them ; — in a word, that interrupted circu- 
lation in the brain is the proximate or immediate 
cause of that temporary suspension of the senso- 
rial functions which constitutes the apoplectic 
stale. To establish this opinion it will be neces- 
sary to show ground for believing, first, that these 
functions are dependent, for their performance, 
upon the continuance of the cerebral circulation ; 
and, next, that all the remote causes, the operation 
of which is at all understood, have a manifest 
tendency to produce such an interrupted state of 
circulation in the brain. If these points are estab- 
lished, it is plain that a different indication of cure 
ought to be followed, from that usually pur- 
sued. 

It can scarcely be doubted, we imagine, that the 
brain, in common with other organs, depends 
mainly for the performance of its functions upon 
the continued circulation of blood through its 
vessels, and without which those functions must 
soon cease to be performed. This dependence of 
the sensorial functions upon the circulation of the 
brain, is shown, first, in the case of syncope,- in 
which the action of the heart ceases altogether, 
or nearly so, for a time ; and, consequently, little 
or no blood is sent to the brain. In this case, the 
sensorial functions are suspended, the patient 
becoming unconscious, insensible to impressions, 
and without voluntary movement. If, on the 
other hand, the return of blood from the brain to 
the heart be obstructed by causes influencing the 
veins, the same interruption is given to the circu- 
lation of the brain, and the same suspension of its 
functions follows. This is seen, where the head is 
made the most depending part, as in stooping, in 
persons who are predisposed to apoplexy : the 
vessels for a time are incapable of carrying the 
blood upwards against gravity, and it necessarily 
therefore stagnates in the vessels of the brain; 
with the same consequence as before, suspension 
of the sensorial functions. Were it practicable to 
tie the internal jugular veins, it can hardly be 
doubted that the same effects would follow ; for a 
less complete obstruction to the return of blood 
from the brain, by these veins, produces similar 
effects ; such, for example, as is occasioned by 
tumours in the neck, or in the course of the supe- 
rior cava, or by disease of the heart or lungs ; all 
of which give a tendency to apoplexv. There is 
so far an analogy between the two states of syn- 
cope and apoplexy, that in both the circulation 
01 the brain is interrupted, and in both the senso- 
rial functions are suspended. The difference is 
not as regards the brain itself, but the rest of the 
oody. In the one case, (syncope,) the blood 
ceases to be sent to the head altogether; but in 
the other case, (apoplexy,) the blood is stagnant 
in the brain only; while the heart continues its 
action, and the general circulation is still carried 



on, the pulse beats, and the vivid hue of the coun- 
tenance is preserved. 

These two cases, of syncope and apoplexy, 
would seem to prove sufficiently that unless the 
circulation of blood through the brain lie continued, 
the organ is incapable of carrying on its functions. 
But while this is admitted, it is of importance also 
to know that the brain is much less dependent 
upon the action of the heart and general vascular 
system than is commonly supposed. It is upon 
the action of its own vessels that the brain chiefly 
depends for the performance of its functions, and 
the modifications which those functions occasion- 
ally undergo, both in health and in disease. We 
frequently observe the action of the heart and 
general vascular system greatly increased and 
disordered, as in acute rheumatism and other active 
inflammations, where the pulse is full and strong, 
and the general circulation carried on with the 
greatest vehemence, and yet the proper functions 
of the brain are undisturbed. This it is not diffi- 
cult to understand, when we advert to the con- 
trivances of nature to guard the brain against any 
violent impulse of the blood, as derived from the 
heart ; by the bony and tortuous canals through 
which the arteries enter the skull, the anastomo- 
ses which take place within, and the minute 
divisions and ramifications which the arteries sub- 
sequently undergo, before they arrive at, and are 
distributed throughout the cerebral substance. 

In other cases, where the blood is sent sparingly 
to the brain, and with the feeblest impulse, — 
where, in fact, the pulse at the wrist is scarcely 
perceptible, and the general circulation is nearly 
at a stand, — the brain nevertheless, preserving the 
action of its own vessels, and thereby maintaining 
its circulation, is found capable of performing some 
of its most important functions ; and that often 
within a few moments of the termination of life. 
In fact, in all the diseases of the encephalon, it is 
the state of action in the cerebral vessels them- 
selves, and hardly at all that of the <renend vascu- 
lar system, which regulates and determines the 
phenomena and effects of the disease. The ex- 
pression therefore, determination of Hood to the 
hcetd, in such general use, appears to be unfounded, 
as implying that the quantity of blood impelled to 
the brain, and the force of circulation there, depend 
in any material degree upon the heart's action, 
instead of the action of the cerebral vessels them- 
selves. 

Of the mode of action of the remote causes of 
apoplexy. — Let us now proceed to inquire how 
far the different remote causes of apoplexy have 
actually a tendency to produce the effect supposed 
— that of interrupting the circulation in the brain, 
and thereby impeding, or more or less perfectly 
interrupting, its functions. 

The simplest remote or occasional cause of the 
apoplectic state is strong pressure made on the 
surface of the brain from without. When, for 
example, the skull is perforated, or otherwise ren- 
dered imperfect, and the point of the linger is 
pressed with a certain degree of force on the brain, 
the animal becomes motionless and insensible — in 
other words, apoplectic; and this continues till 
the pressure of the finger is removed. According 
to the theory proposed, it is obvious that such 
pressure must of necessity have the effect of ob- 



APOPLEXY, (CEREBRAL) 



149 



structing, more or less, the circulation of blood 
through the organ. From the incompressible na- 
ture of the cerebral substance, such pressure may 
affect the vessels situated in the remotest parts of 
the brain, as readily as those to which the pressure 
is more immediately applied. Here, therefore, as 
far as the circulation of the blood in a part is 
ary to the performance of its functions, we 
hive an adequate cause of the suspension of 
functions which characterises apoplexy. In like 
manner, fracture of the skull, with depression of 
a portion of bone, or blood extravasated beneath 
it, equally induces an apoplectic state, by com- 
pressing the blood-vessels, and which is seldom 
relieved till the depressed portion of bone is 
elevated, and the extravasated blood removed. 

Extravasation of blood, or serous accumulation 
in the interior of the brain, must necessarily have 
the same effect, by taking up space which can 
only be furnished by the blood-vessels yielding to 
the pressure thus made upon them. In all these 
cases it is evident that the circulation of blood 
through the brain must be impeded or interrupted, 
in different degrees, according to the extent of the 
pressure so applied. If this should be great, and 
suddenly induced, such a degree of stagnation 
may take place, as to be incompatible with life 
itself. 

Again, if a tumour is formed within the skull, 
whether it be a morbid production of any kind, or 
a case of common inflammation ending in abscess, 
in cither case space is required, which can only be 
supplied, either by the removal of a corresponding 
portion of cerebral substance by the slow process 
of absorption, or by the emptying of the blood- 
vessels of the brain, as the natural consequence 
of the pressure which such tumour is making on 
the surrounding parts. 

In all the cases above described, simple observa- 
tion, or dissection, will illustrate the nature of the 
disease, by pointing out the immediate cause of 
the impeded or interrupted circulation in the brain. 
But there are other cases of apoplexy, in which 
dissection detects nothing adequate to explain the 
symptoms ; which, therefore, must be otherwise 
accounted for. 

It has been a very generally received opinion 
that such an increased determination of blood to 
the brain may take place as to give rise to an 
overloaded state of its vessels, so as to disable it 
for the performance of its functions, or, in other 
words, to induce an apoplectic state. 

This supposed determination of blood to the 
brain, and the impeded state of functions arising 
out of it, have been ascribed to increased action 
of the heart. But it has been already shown, 
that the brain is incapable of receiving any addi- 
tional quantity of blood in its vessels ; conse- 
quently, there can be no such over-fulness as has 
been supposed, to account for the oppressed state 
of the organ. And were it otherwise, the heart 
has no power of sending blood to the brain in 
greater quantity than to other parts. If the force 
of circulation in the brain be increased, as it un- 
doubtedly may be, such an effect is owing to the 
increased action of its own vessels, and not to that 
of the heart. The phrase, determination of blood 
to the brain, is, therefore, without meaning. 
Much has been said of late of venous conges- 

N * 



tion, as one of the immediate causes of the apo- 
plectic state. This notion is founded, as before 
observed, solely upon the fact, that in some cases 
of apoplexy, the superficial veins on the surface 
of the brain are found gorged with blood. Hence 
it has been imagined that the same state of veins 
existed during life. It is, however, a great error 
to suppose that the appearances observed in the 
body alter death are a true representation of what 
existed during life, especially as regards the blood- 
vessels. It is a general principle in physiology 
that the arteries, in consequence of the greater 
degree of contractile power naturally possessed by 
them, empty themselves into the veins, as their 
last act of life ; and accordingly the blood is prin- 
cipally found in the veins upon dissection. This 
law applies to the brain no less than to other parts: 
and consequently the veins, which are principally 
situated on the surface of the brain, running be- 
tween the convolutions, are always found more or 
less distended with dark or venous blood ; while 
the principal arteries, situated towards the basis, 
are found comparatively empty. Now no one can 
believe that this state of the arteries and veins of 
the brain, relatively to each other, could exist — 
that the arteries could be empty and the veins full, 
during life ; for such a state of things would be 
clearly incompatible with the regular movement 
of the blood, which requires that there should be 
a continuous stream throughout the vascular sys- 
tem. The blood which the veins contain, what- 
ever be its quantity, must be derived from the arte- 
ries ; and if there be found, after death, a more 
than usual quantity of blood in the veins, — if 
they are in a congested state, (to use a modem 
though unphilosophical expression,) or unusually 
gorged with blood, — it is only a proof that the 
arteries, at the time of death, had sent into them 
an extraordinary quantity of blood; and that they 
had probably been unusually distended during 
life. This is confirmed by the fact that such a 
gorged state of the veins on the surface of the 
brain is met with in those cases of disease in 
which the arterial action of the organ during life 
has been the most violent. 

The term congestion, therefore, as implying an 
unusually distended state of vessels in the brain, 
applies to the arteries, and not to the veins ; the 
gorsred state of the latter taking place only at the 
time of death. The importance of this distinction 
will be seen, in laying down the treatment of apo- 
plexy, as well as other acute cerebral diseases. 

It remains to be shown, how such a distended 
state of the arterial system of the brain is calcu- 
lated to produce the apoplectic state, by impeding 
the circulation through the organ. This will be 
best illustrated by showing how the state called 
intoxication, or drunkenness, is produced by alco- 
hol, or other inebriating liquors. Alcohol, in all 
its combinations, and however applied to the body, 
proves a stimulus to the arteries of the brain ; and 
in whatever way it produces its peculiar or specific 
effects, its action may be justly termed specific 
with respect to this organ, as it produces nothing 
similar, at least in an equal degree, on any other 
This specific and stimulant power of alcohol with 
regard to the brain, is evinced by unequivocal 
proofs of increased arterial action in the whole 
head ; as well as by the disturbance in the state 



150 



APOPLEXY, (CEREBRAL) 



of the sensorial functions which it occasion*. 
The increase of action in the external carotid 
arteries is manifested by the stronger pulsation 
and increased size of both the cervical and tempo- 
ral arteries, and by the flushing of the face, and 
redness of the eyes ; all of which clearly show 
increased action in the branches of the external 
carotid : and that a similar state of excitement 
takes place in the internal arteries of the head and 
their ramifications throughout the brain, may be 
inferred with great probability from the increased 
heat of the whole head, and from the feelings of 
the individual, especially when recovering from 
the effects of intoxication ; at which time there 
is frequently violent throbbing head-ach. 

Admitting, then, that the peculiar and specific 
effect of alcohol is to stimulate and excite the 
blood-vessels of the brain to greater action, it will 
not be difficult to account for the different and 
even opposite effects of the same stimulus, accord- 
ing to the degree in which it is applied, and the 
time that has elapsed from its administration : and 
certainly nothing can well be more different than 
the effects produced by a moderate use of wine, or 
other strong drinks, and the highest state of 
drunkenness. In the one case, the greatest energy 
and activity are displayed throughout the system 
— in the other, some of the most important func- 
tions of the brain are nearly annihilated. This 
apparent incongruity of symptoms, however, will 
vanish, if we advert to the effects of stimulation 
on arteries in general, as applied in different de- 
grees ; and, at the same time, recal to our recol- 
lection the peculiar physical circumstances in 
which the brain is placed, as already noticed. 

A moderate degree only of excitement of arte- 
ries merely increases their action, and augments, 
in consequence, the impetus and velocity of the 
blood through them, but without manifestly, or at 
least considerably, increasing their diameters. 
Under a more powerful degree of excitement, 
their diameters become enlarged ; the quantity of 
blood in them is increased, and at the same time 
put into more rapid motion. These effects may 
be readily seen upon immersing an extremity, the 
arm for example, in hot water : both arteries and 
veins become enlarged ; the blood circulates with 
greater force and velocity ; and the bulk of the 
whole limb is increased. 

The same law doubtless holds good with respect 
to the blood-vessels of the brain. There is the 
same tendency as in other parts to enlarge their 
dimensions from the application of stimuli ; but 
with this difference, that from the peculiar circum- 
stances in which this organ is placed, as before 
pointed out, there is not room for the simultaneous 
expansion of both arteries and veins. The arte- 
ries becoming enlarged in their diameters, as a 
consequence of their increase of action, occupy 
greater space within the skull than before, and in 
so doing necessarily compress the veins, these lat- 
ter being the only parts that yield to pressure. It 
is obvious, then, that the movement of the blood 
through the brain must be impeded, in proportion 
as the veins are suffering compression ; and this 
again will depend upon the degree of excitement 
und distension that exists in the arteries : and 
thus the different degrees and successive stages of 
intoxication are easily understood : in the first 



degree of excitement, by a moderate use of vinoua 
liquors, the movement of the blood through the 
vessels of the brain is augmented ; the anion of 
the arteries being simply increased, without any 
material increase of their dimensions, the veins 
are still in a condition to receive and to transmit 
the aiterial blood. In this state of the circulation 
of the brain, the sensorial functions are simply 
excited, but without disorder; the powers both of 
body and mind are displayed with greater energy ; 
but in a higher state of excitement from the same 
cause, the arteries of the brain become distended, 
the veins arc pressed upon, and the circulation is 
proportionally impeded. Disorder of functions 
then succeeds to the previous state of simple ex- 
citement ; and if the stimulus be carried to the 
highest excess, the circulation of the brain becomes 
almost wholly interrupted ; and the consequence 
soon is an entire abolition of all the sensorial 
functions, or in other words, the highest degree of 
intoxication. This state continues till the excited 
and distended arteries gradually subside into their 
former and natural state of action and fulness ; 
when the pressure is taken off from the veins, and 
the circulation through the organ is renewed : 
with this, a restitution of its functions takes place, 
the stupor gradually disappearing. 

Another cause of excitement of the arterial 
action of the brain is the hot-bath ; and, still 
more, the direct application of heat to the naked 
head, as in the coup-de-solcil, to which we have 
before adverted, both of which occasionally give 
rise to apoplexy ; which however is generally 
temporary in duration, and for the most part with- 
out danger ; unless, from the violence of action, 
a rupture of vessels should take place, or inflam- 
mation should follow, when the character of the 
disease becomes changed. The apoplectic stupor 
that attends both of these cases, whether produced 
by the hot-bath or by insolation, admits of a ready 
explanation upon the principle of arterial fulness, 
as before illustrated. 

Again, the arterial action of the brain is strong- 
ly excited by certain emotions of mind, particu- 
larly anger and joy ; both of which, when exces- 
sive, have been found to induce apoplexy, anil 
sometimes with a fatal result. They may easily 
be conceived to operate in the way mentioned: 
namely, by arterial fulness producing venous com- 
pression, and consequently interrupted circulation 
in the brain. 

Lastly, inflammation of the brain, when gen- 
eral or extensive, whether it be a primary affection 
or arising in the course of other diseases, not un- 
frequently terminates in apoplectic stupor. At 
the commencement, just as in the early stage of 
intoxication, there is excitement, with more or 
less of disorder, in the sensorial functions : as the 
inflammation increases, the disorder of functions 
increases likewise ; there is then frequently furi- 
ous delirium. At length, stupor takes place, and 
the patient often dies apoplectic. Of all these 
changes we have frequent examples, in the cases 
of hydrocephalus, phrenitis, and idiopathic fever; 
these differ from ordinary cases of apoplexv, in 
possessing the characters of inflammation along 
with those of oppressed brain. In all, the same 
cause of cerebral oppression exists ; namely, ob- 
structed circulation induced immediately by arterial 



APOPLEXY, (CEREBRAL) 



131 



fulness ; which, in a circumscribed space, as that 
of the skull, must of necessity compress the only 
yielding parts, the veins, and thereby impede, and 
in extreme cases put an entire stop to, the circu- 
lation of the brain, and thus destroy life. 

Thus it appears that apoplexy may be produced 
by a variety of remote causes, all operating in 
different ways, but all leading to the same gen- 
eral result — obstructed circulation of the brain. 
Whether this be produced by direct external pres- 
sure, or by extravasated fluids, or tumours, within 
the skull ; whether by arterial excitement and 
consequent distension, as produced by either 
alcohol, external heat, or mental emotions; — or 
whether by any impediment to the return of blood 
from the brain, by causes influencing the veins ; 
— the effect is still the same, and suggests the 
same general indication of cure; namely, to re- 
store the circulation of the brain. The means, 
however, of doing this will vary according to the 
nature of the obstructing cause, the removal of 
which is the principal object of practice. 

It may be asked here, is there any cause (not 
mechanical) capable of influencing the sangui- 
ferous syst m of the brain exclusively, so as to 
paralyse, as it were, its blood-vessels, and thereby 
put a stop to the movement of the blood in that 
organ ' Is apoplexy ever induced in this manner ? 
Has carbonic acid, or any of the narcotic tribe, 
such a power ? Is natural sleep, in which the 
sensorial functions are all suspended, the result 
of diminished action in the blood-vessels of the 
brain, and consequent retarded movement of the 
blood through the organ ? And may not dream- 
ing and somnambulism be explained on the sup- 
position that some parts of the vascular system 
of the brain continue in an active state, while the 
rest become quiescent ? These are important 
questions, to which, however, a satisfactory answer 
can hardly be given in the present state of our 
knowledge. The insensibility induced by extreme 
cold may perhaps be so explained. The subject 
altogether merits consideration. 

The prognosis in apoplexy is governed, in some 
measure, by the actual condition of the brain, and 
also by the nature of the remote cause, and the 
possibility of its removal. This will be best un- 
derstood when we come to the particular treat- 
ment of the disease under its different circum- 
stances. It may be observed in general, that a 
very large proportion of cases of apoplexy termi- 
nate fatally ; some of them immediately, some 
after a longer interval. Those that do not prove 
immediately destructive to life, are often fatal on 
recurrence, though repeated attacks may inter- 
vene. Cases that depend upon vascular excite- 
ment merely, without lesion of structure, and 
without extravasation of blood, or accumulation 
of serum in the brain, may be judged of favour- 
ably. But as these points can seldom be deter- 
mined with certainty during life, the prognosis in 
apoplexy is always more or less doubtful, and for 
the most part unfavourable. 

Treatment. — There is perhaps no disease 
the treatment of which requires so much to be 
directed by theory or general principles as apo- 
plexy. The practice in general use is, for the 
most part, unnecessarily violent ; and, in some 
respects, contradictory. Bloodletting to an un- 



reasonable extent, vomiting, purging, blistering, 
sinapisms, and a variety of other stimulants, have 
all been administered with an almost indiscrimi- 
nate and unsparing hand ; as if, to insure re- 
covery, it were only necessary to have recourse to 
sufficiently active means, without much regard 
being paid to their nature or effects. The treat- 
ment thus becomes needlessly complicated and 
severe ; and there is reason to believe that the end 
sought after is often thereby frustrated rather than 
promoted. It is necessary, in order to practise 
with success, to look not only to the symptoms, 
but to the intrinsic nature of the affection ; ami 
more especially to the various remote causes by 
which the disease may be induced, the obviating 
of which is the principal object of attention in 
the cure. Without these distinctions being made, 
the treatment becomes little more than empirical. 
It is above all things necessary to guard against 
the profuse and almost unqualified use that is 
made of the lancet on those occasions, apparently 
without consideration of what it may be really 
capable of effecting, and what it is incompetent 
to perform. By injudicious application, it will 
not only fail to do good, but may impede recovery, 
and even tend to destroy life. 

Admitting that the proximate or immediate 
cause of apoplexy in general, as far at least as 
this is understood, is impeded or interrupted cir- 
culation of blood in the brain, the simple ai»<i 
obvious indication of cure to be followed, is to 
restore the circulation so obstructed ; which is i:i 
general only to be accomplished by the removal 
of the obstructing cause. This being various, 
and different at different times, may require dif- 
ferent and even opposite means for its removal 
It becomes necessary, therefore, to show the in 
dividual treatment of apoplexy, in relation to its 
exciting or occasional cause ; and for this purpose 
it will be useful to follow the order laid down in 
speaking of the various remote causes of the dis- 
ease. These may be usefully arranged under 
three heads, viz. : 1st, such as act by mechanical 
pressure on the brain ; 2d, such as act by pro- 
ducing arterial excitement and distension ; and, 
3d, such as occasion impediments to the return of 
blood from the brain by the veins. 

1. Treatment of apoplexy in reference to the 
first division of causes. — When apoplexy is in- 
duced by fracture of the skull with depression, or 
where blood is effused immediately beneath the 
bone, the treatment is simple ; consisting prin- 
cipally in the elevation or removal of the depress- 
ed portion of bone. The means of accomplish- 
ing this are within the province of surgery. The 
after-treatment consists in endeavouring to pre- 
vent and to remove inflammation by bloodletting 
and other analogous remedies. 

An interruption or suspension of the sensorial 
functions may take place as the result of external 
violence, in which there is no injury done to the 
bone, nor other source of pressure on the brain. 
This has been referred to concussion simply, or 
the shock which the organ has sustained from the 
fall or blow received. The injury done to the 
brain in some of these cases is so great, as to 
prove immediately or quickly fatal ; and yet, upon 
dissection, nothing has been found adequate to 
explain the effect. At other times vessels have 



152 



APOPLEXY, (CEREBRAL) 



been ruptured, and Mood found effused, sufficient 

to explain the apoplectic state. It is not possible, 
at all times, to distinguish, during life, between 

the effects of simple concussion, and those arising 
from the pressure of extravasated blood in the. 
brain ; and tin- difficulty is the greater from the 
circumstance, that the case is often complicated ; 
the same degree of violence that occasioned a 
rupture of blood-vessels, almost of necessity pro- 
ducing a considerable shock to the brain. The 
distinction, in regard to symptoms, that has been 
supposed to exist in the two cases of concussion 
and extravasation, is by no means to be relied 
upon. Still less does there appear to be a foun- 
dation for the widely-different methods of cure, 
that have been proposed with respect to them. 
The older writers on surgery relied principally 
upon bloodletting in cases of supposed concussion, 
as well as in other injuries of the brain. The 
moderns, some of them at least, influenced pro- 
bably more by love of novelty than real observa- 
tion, condemn in toto the practice of bloodletting, 
and recommend, instead of it, a totally opposite 
mode of cure ; namely, the use of opiates and 
general stimulants. In neither case does the view 
that has been taken of the subject appear to be 
altogether correct ; nor is the practice recommend- 
ed at all times consistent with reason. Experi- 
ence, which has been adduced in favour of both 
modes of practice, cannot be implicitly relied 
upon. Upon the supposition that the brain has 
suffered only from the shock, without depression 
of bone, or extravasation of blood, it is not con- 
ceivable that bloodletting should be capable of 
affording any immediate, relief. The medullary 
substance may have been deranged, or have un- 
dergone an imperceptible solution of continuity 
in the minuter parts of its structure ; or its vital 
properties may have been simply affected, without 
physical or mechanical injury ; but in neither case 
is bloodletting an indispensable remedy. There 
is one point of view, however, in which blood- 
letting may be considered of importance ; and 
that is, in regard to its power of preventing in- 
flammation, which is an almost necessary conse- 
quence of such violence committed on the brain. 
The propriety of bloodletting, however, will still 
be to be governed by circumstances, and especial- 
ly by the state of the general vascular action ; 
which differs considerably in different instances. 
In some cases of simple concussion of the brain, 
the genjral circulation is carried on very feebly ; 
the pulse is weak and soft, with varying fre- 
quency ; and the body is cold. Such a state can 
hardly be supposed to require, or even to bear, 
loss of blood. At other times, the action of the 
general vascular system is little altered from the 
natural state. In such cases, the moderate ab- 
straction of blood would be safe and proper, as a 
means of preventing subsequent inflammation. 
It is scarcely necessary to add, that if the pulse at 
the wrist is fuller or stronger than natural, (as 
may be the case from the first, or it may take 
place at some period after the infliction of the 
injury,) there need be no hesitation as to the free 
abstraction of blood ; limited, of course, by the 
general strength and other circumstances of the 
patient. But, admitting that bloodletting is not 
squired in any particular case of concussion of 



the brain, docs it follow that opiates or stimulants 
should be proper ? What possible tendency can 
either of these have to relieve the injury which 
the brain has sustained, either with regard to its 
physical or vital properties? Even should the 
general circulation be greatly depressed, still it is 
not easy to sec how exciting it by active stimu- 
lants should be productive of much good, as they 
arc not likely to produce lasting good effects, nor 
have they any tendency to remove the cause; 
namely, the injury the brain has suffered. On 
the other hand, if largely used, they may increase 
the tendency to inflammation, and thus become 
objectionable. Upon the whole, except the em- 
ployment of bloodletting in the circumstances and 
with the view now mentioned, the variety of apo- 
plexy that results from what is termed concussion 
of the brain, admits only of very simple treat- 
ment. With the exception of inflammation, the 
prevention and cure of which are objects of great 
importance, relief can only be hoped for from 
time, and a quiet state of the organ. 

Apoplexy arising from the extravasation of 
blood in the brain, (that form of the disease which 
has attracted the greatest notice,) cannot be cer- 
tainly known during life, though it may often be 
suspected. When the disease occurs suddenly 
and with violence ; or, beginning mildly, gradu- 
ally gets worse ; and when the stupor continues 
for many hours, and is then followed by only an 
alleviation of symptoms ; there is strong ground 
for believing that a rupture of blood-vessels has 
taken place in the brain. This is a case in which 
bloodletting has been used with little discrimina- 
tion, and often, there is reason to believe, carried 
to a hurtful excess. It is evident that the remedy 
can have no direct effect in removing the extrava- 
sated blood ; nor can it lessen the quantity of 
blood altogether within the skull, so as to give ad- 
ditional space, and thereby diminish the pressure 
the effused blood is making on the brain ; and 
yet it is employed in these cases as if it were ca- 
pable of accomplishing, with certainty, one or 
other of these purposes ; it is used too with such 
freedom, as if it needed only to be carried to a 
certain extent in order to insure success. But 
blood, once extravasated, can be removed only by 
absorption, which is a natural and slow process, 
requiring for its completion at least a moderate 
share of general strength. Large and unnecessary 
abstraction of blood in such cases, by weakening 
the body altogether, rather creates an obstacle to 
recovery than the contrary. The proper use of 
bleeding in such cases is, to reduce that violence 
of arterial action in the brain (often of a real in- 
flammatory nature) upon which the rupture and 
effusion immediately depend, and thereby to pre- 
vent a further escape of blood. But for such a pur- 
pose, only a moderate though perhaps repeated ab- 
straction of blood can be required; and then always 
in proportion to the age and other circumstances 
of the patient, and according to the stage and 
duration of the disease. As mere matter of expe- 
rience, there is reason to believe that bloodletting 
in these cases does much less good, and the omis- 
sion of it less injury, than is generally supposed. 
As to the other remedies in general use on these 
occasions, little can be said in their favour, while 
some of them are decidedly hurtful in their tfn- 



APOPLEXY, (CEREBRAL) 



153 



ilcncics : such is the case with extensive blister- 
ing, or sinapisms, and internal stimulants of any 
considerable activity. From the very nature of 
the case, they can accomplish nothing beneficial ; 
while the immoderate use of them may do harm, 
oy exciting the general vascular action of the sys- 
tem. Vomiting is for the most part objectionable, 
and may be even dangerous, by the temporary 
check it gives to the return of blood from the 
head. Even where it is known or suspected that 
the stomach is in a loaded state, the danger at- 
tending full vomiting is more than a counterpoise 
to any benefit likely to be derived from the prac- 
tice. Sneezing, which has been sometimes re- 
commended for the relief of the stupor, is little 
less hazardous than the use of emetics. 

The treatment of apoplexy dependent upon ac- 
cumulation of serous fluid in the brain, or, as it is 
termed, serous apoplexy, requires a further con- 
sideration. It has been already stated that no ab- 
solute line of distinction can be drawn between 
the sanguineous and serous forms of the disease ; 
thry are, in fact, frequently found in combination, 
or rather to be considered as mere varieties of one 
and the same affection. Serous accumulations 
in any of the cavities of the body are in most in- 
stances the result of membranous inflammation ; 
not in general of an acute, but rather of a chronic 
or protracted description. This primary depend- 
ence of serous accumulations, or dropsies as they 
arc called, on inflammation, is not always distinct- 
ly seen, on account of the mildness of the inflam- 
matory symptoms at first, and their having often 
passed away without notice, leaving the accumu- 
lation of fluid behind. Still, there are but few 
cases in which the connexion of dropsy with in- 
flammation, as its primary source, may not be 
traced by accurate inquiry. This applies to the 
brain, as much as to either of the other cavities. 
In most apoplexies that come on slowly, and 
which, on this account, are supposed to be of a 
serous nature, signs of preceding as well as of 
existing inflammation in the cavity may be dis- 
covered ; such as head-achs, sometimes accompa- 
nied with flushing and throbbing of the arteries 
about the head ; together with more or less of 
general febrile action throughout the system, 
(which last is to be taken as an infallible criterion 
of the existence of topical inflammation in some 
organ,) to say nothing of the disturbance of func- 
tions which marks the seat of the disease. Mere 
serous accumulations, without other disease of the 
organ, may account for a lethargic state of the pa- 
tient, but is hardly sufficient to explain the oc- 
currence of an apoplectic fit : which, being sudden 
in its attack, and disposed to recur by paroxysms, 
must depend upon some occasional and temporary 
cause, and not upon the mere presence of the 
fluid ; for this must be slowly collected, and when 
once formed must be permanent, or, at all events, 
is not likely to be rapidly absorbed. No tempo- 
rary cause of such disturbance, or rather suspen- 
sion, of functions as takes place in apoplexy can 
be suggested with so much probability as occa- 
sional arterial excitement, to which the brain ap- 
pears to be particularly prone. Such a disposi- 
tion to occasional arterial excitement is a natural 
consequence of inflammation, and may remain 
long after the inflammation which gave rise to it 

Vol. I. — 20 



has disappeared. And thus it is that persons 
liable to apoplexy of this mild description, sutler 
a great number of slight attacks with impunity : 
but in general arc at length carried oft' by one of 
greater violence; and then it is usually found, 
upon examination after death, that extravasation 
of blood has produced the fatal event ; proving 
that there is no real or essential distinction to be 
made between serous and sanguineous apoplexy. 

In the treatment of apoplexy of this nature, 
slow in its approaches, and occurring, as it occa- 
sionally does, in feeble habits, a mild plan of cure 
only is admissible. Inquiry is to be made as to 
the probable existence of inflammation, its degree 
and duration ; and remedies applied accordingly. 
In no case, even during the fit, could a large ab- 
straction of blood be proper. Such a remedy, 
supposing the fit to be the immediate result of 
arterial excitement merely, without a rupture of 
vessels, is unnecessary, as the increased vascular 
action will probably subside by milder means, or 
even spontaneously ; while, should effusion have 
actually taken place, the largest bloodletting 
could effect nothing direct towards its removal, 
and might even prove immediately fatal. At all 
events, the patient would be left in a less favour- 
able state for future recovery. It is here as in 
epilepsy, in which, during the paroxysm, unless 
the disease altogether be of recent occurrence, little 
can be done with advantage. It is in the inter- 
vals, for the most part, that we can hope the mea- 
sures adopted will be permanently advantageous. 
So in apoplexy, of the description here alluded to, 
the paroxysm, however alarming in appearance, 
is either of no real importance, or, if it should be 
dangerous from rupture of vessels, or other injury 
sustained by the part, art can do little or nothing 
for its relief. In the intervals, and when a sus- 
picion of inflammation no longer exists, it may 
be proper to aim at removing the serous deposit, 
by diuretics or other such methods as are not par- 
ticularly detrimental to the general health. In 
this point of view, the employment of mercury, 
however highly vaunted on these occasions is of 
very equivocal use. 

Serous accumulation in the brain appears to 
take place at times, as a consequence of impedi- 
ments to the return of blood by the veins : hence 
the stupor that is observed to occur in some pul- 
monary affections, in which the blood is not trans- 
mitted with freedom through the lungs. This, 
however, is rather lethargy than apoplexy, as it 
does not occur by fits, unless there should be 
actually at the same time disease in the brain 
itself. 

With respect to tumours, or other alterations 
of structure, observed in the brain of persons dying 
of apoplexy, such are to be considered rather as 
predisposing, and not as efficient, causes of the 
apoplectic state. Being permanent in their nature 
when once formed, they can afford of themselves 
no adequate explanation of a paroxysm or fit that 
is only of occasional occurrence. This, as was 
observed on a former occasion, must be referred 
to temporary vascular excitement, the disposition 
to which is produced and kept up by the presence 
of the morbid structure. Apoplexy may be sus- 
pected to be of this nature, when preceded or ac- 
companied by symptoms denoting the existence 



154 



APOPLEXY (CEREBRAL) 



of chronic inflammation in the brain. These mor- 
oid changes of structure are generally found in 
combination with more or less of serous effusion. 
Should apoplexy take place under such circum- 
stances, bloodletting might be required for the im- 
mediate relief of the fit, but not to any great ex- 
tent ; the object being merely to diminish the arte- 
rial action of the brain, and thereby to put a stop 
to that temporary state of excitement which is 
the immediate cause of the paroxysm. In this, 
as in other cases, sanguineous effusion may have 
taken place ; but of this no certain knowledge 
can be obtained till after death. If it were even 
possible to ascertain it during life, it would afford 
no additional ground for profuse bloodletting. 
Should the patient survive the fit, it is then an 
important object to endeavour to remedy the dis- 
organization w r hich we may suspect to exist in the 
brain, or rather to take off the inflammatory action 
in the part, which has produced the alteration of 
structure ; for over the morbid structure itself art 
has little influence. It is, however, only in slight 
and recent affections of the sort, that we can hope 
to be successful ; though much may still be done 
to mitigate and to check the further progress of 
the mischief. The means we have it in our 
power to employ for the purpose are few and sim- 
ple. Small and repeated bloodlettings afford the 
best, if not the sole chance of success in such 
cases. To enable the patient to bear these for as 
long a period as may be necessary to accomplish 
the purpose, it is indispensable that he be allowed 
to take food in reasonable quantity, and of the 
most simple digestible kind. There is no better 
guide, perhaps, on these occasions, than the natu- 
ral appetite, when not excited by variety or by 
food of a stimulant nature. It is a great mistake 
to suppose, either in this or in other chronic dis- 
eases requiring bloodletting, that the attainment 
of our object is likely to be frustrated by a mode- 
rate use of food, whether animal or vegetable in 
its nature. Judging from experience in chronic 
forms of inflammation, the contrary rather appears 
to be the case. An unfounded preference appears 
to be given to what is called local or topical bleed- 
ing over venesection. The term topical or local 
is quite misapplied here, as no vessel immediately 
connected with the brain, or that can directly in- 
fluence its circulation, admits of being opened 
for the purpose of letting blood. It is to quan- 
tity, and the rapidity of taking away blood, that 
we are to look, and not the part from which the 
blood is taken ; unless indeed it could be drawn 
immediately from the part affected ; which is of 
course impracticable. The circulation of the dis- 
eased part, as far as regards the abstraction of 
blood, can only be influenced through the medium 
of the general circulation ; and this we can more 
icadily and effectually act upon by venesection or 
i-eneral bloodletting, than by what is termed local 
bleeding ; simply because we have a command, 
both as to time and quantity, in the one case, 
which we seldom can have in the other. The 
safety of bloodletting, in both modes, depends upon 
quantity • but not so the efficacy of the practice. 
It might noi indeed be prudent, or even safe, in 
all cases, to abstract blood so rapidly as to induce 
fainting. In general, this had better be avoided ; 



both as being seldom necessary, and as generally 
alarming in appearance. 

The other means in use for the treatment of 
chronic inflammatory disease in the brain, such as 
purgation and counter-irritation by blisters, issues, 
or the like, are of very inferior importance in com- 
parison with bloodletting, in cases admitting of 
the latter. A long-continued and rather severe 
employment of mercury has to all appearance been 
attended with success in many instances ; but in 
many also it has failed. In the use of it, we arc 
not to forget its power of doing harm as well as 
good. 

The treatment of the second order of apoplexies, 
those that arise simply from high arterial action 
and distension of the vessels of the brain, without 
extravasation or serous effusion, and without dis- 
organization, is of a simpler kind, and more likely 
to be attended with success. Ordinary cases of 
intoxication, from the excessive use of strong 
drinks, in general require only quiet and repose 
for a few hours ; in the course of which the vascu- 
lar action of the brain subsides into its natural 
state, and often indeed falls below it, so that a 
stimulus of the same kind afterwards is found to 
relieve the feelings of depression that generally 
succeed. In aggravated cases, however, of thiu 
description, and especially in persons unaccustomed 
to the use of strong drinks, more active measures 
may be called for ; such as bloodletting to a mode- 
rate extent, and purging, in order to subdue, more 
quickly and effectually, the vascular excitement 
of the brain. These should be accompanied with 
the moderate application of cold to the head, with 
a view both to its sedative and its constringing 
properties, in the hope that these effects may be 
communicated by sympathy from the external to 
the internal vessels of the head. There is another 
good reason for the employment of such means in 
aggravated cases of intoxication, namely, that of 
guarding against inflammation of the brain, which 
now and then results from this cause. 

When the narcotic effects of opium and drugs 
of the same class occur in an alarming degree, a 
very similar mode of treatment is required. In 
regard to the use of bloodletting in both cases, 
attention must be paid to the state of the general 
circulation. A soft and feeble pulse, with cold 
extremities, would not admit of bloodletting, but 
might require, on the contrary, the use of simple 
stimulants, such as ammonia, together with fric- 
tions and external warmth. Heat of the head, 
and throbbing of arteries, which are often found. 
even where the surface and extremities arc much 
chilled, call for the application of cold to the head, 
as well as in the case of intoxication. The prac- 
tice generally inculcated, in cases of poisoning by 
opium, is to endeavour to keep the patient from 
falling asleep, by every possible mode of irritation ; 
if such treatment be proper in the case of opium. 
one does not see why it should not be also adopted 
in cases of intoxication by alcohol ; for the symp- 
toms are nearly alike in the two cases. If the 
stupor or suspension of the sensorial functions 
produced by narcotic substances be owing to an 
excited and distended state of the arteries of the 
brain, irritation of any kind will only prove an 
additional cause of vascular excitement in the 



APOPLEXY, (CEREBRAL AND PULMONARY) 



155 



brain. It would be well if a satisfactory appeal 
could be made to experience, in order to decide 
the point of practice : but this can hardly be done, 
on account of the difference which exists between 
different cases. 

Should the apoplectic state have been occasioned 
by isolation, the hot hath, or mental excitement, 
the treatment is simple. Moderate loss of blood, 
purgation, and the application of cold to the head, 
would seem to comprise all that can be really 
useful. If, after the lapse of a few hours, con- 
sciousness should not return, the probability will 
be that the violence of arterial action in the brain 
has been followed by the extravasation of blood ; 
the proper management of which has been already 
pointed out. 

Apoplexy is not an unfrequent consequence of 
inflammation of the brain, whether this exist in 
the form of membranous inflammation (hydro- 
cephalus acutus of infants); of phrenitis ; or of 
idiopathic fever, so called. In each of these cases, 
when so violent as to threaten a fatal termination, 
a comatose state bordering on apoplexy takes 
place ; the apoplectic symptoms being mixed up 
with and modified by those of inflammation. This 
termination of inflammation of the brain it is not 
difficult to understand. In the early stage of those 
affections, the vascular excitement of the brain is 
moderate in degree, and not attended with any 
considerable distension of vessels. The circulation 
then is not materially impeded, and the functions 
of the organ are still carried on, though in an 
excited and disordered way. In the further pro- 
gress of the disease, the distension of arteries in- 
creases ; the circulation is by degrees obstructed ; 
and this is soon followed by an interruption, first, 
of the primary functions of the brain, sensation, 
voluntary motion, and intellect ; next, the vital 
functions, respiration, and the general circulation 
suffer, and life becomes extinct. The treatment 
requisite in all these cases is the same ; namely, 
that which is adapted to subdue inflammation in 
general ; regulated, however, by the circumstances 
of the patient, and most particularly by the stage 
of the disease. When the apoplectic state shows 
itself early, there is no question as to the propriety 
of bloodletting, and that with freedom. In an 
advanced stage, and especially when the general 
circulation is failing, this remedy becomes equivo- 
cal, and must be used, if at all, with reserve and 
caution. 

The third variety of apoplexy, namely, that 
which arises from an interruption to the return of 
blood from the brain, requires a different mode of 
treatment from the others, on account of the diffe- 
rent nature of the causes producing it. This is 
the state to which the term venous congestion has 
been applied, but which is nothing more than 
stagnation of blood in the cerebral vessels, a state 
which must necessarily take place if the returning 
current of blood by the veins be impeded or inter- 
rupted. As this interruption may be produced by 
different causes, there will be some difference in 
the treatment. In the simplest case of impeded 
return of blood from the brain, that occasioned by 
a dependent posture of the head, all that is com- 
monly required is to raise the head. Should the 
stupor be occasioned by tumours in the neck, or 
in the course of the veins towards the heart, our 



being able to give effectual relief will depend upon 
our ability to remove or lessen the obstructing 
cause. In the case of violent and extensive in- 
flammation of the lungs, where, from the swelling 
of parts, the blood finds its way sparingly and 
with great difficulty through the lungs, the impedi- 
ment to the return of blood from the head, as well 
as other parts, is seen in the livid hue of the cheeks 
and lips, in the bloated state of the face and neck, 
and in the stupor, or imperfect performance of the 
sensorial functions. Along with these, the pulse 
at the wrist becomes soft, feeble, and often irregu- 
lar ; and the extremities cold. Such a state of 
things is nearly hopeless ; for it scarcely admits 
of relief from art. The feeble state of the general 
circulation will hardly admit of loss of blood ; 
while there are no other means that promise a 
better result. The practice of giving stimulants 
on those occasions, merely because the pulse is 
weak, and because bloodletting is not admissible, 
is supported neither by reason nor by experience : 
such practice is, in fact, in opposition to both. 

In the more chronic cases of obstructed circula- 
tion, arising from disease about the heart and 
lungs, a disposition to apoplexy is gradually 
formed, which may destroy the patient, if he is 
not previously cut off by the primary disease. 
Apoplexy thus induced is commonly of the serous 
kind ; it takes place slowly, from effusion conse- 
quent upon long-continued impeded circulation in 
the brain, and rarely admits of remedy. If, how- 
ever, the primary disease in the heart or lungs is 
in a favourable state for the employment of reme- 
dies ; that is, if the inflammation be not of very 
long standing, the organization not materially 
deranged, nor the general strength much impaired, 
there is still a chance that a cautiously-conducted 
plan of treatment, adapted to the relief of chronic 
inflammation, such as has been pointed out above, 
may rescue the patient from destruction. A result 
so favourable, however, is seldom to be expected. 
H. Clutterbuck. 

APOPLEXY, Pulmonary. The term pul- 
monary apoplexy has been adopted by modern 
pathologists to signify an effusion of blood into 
the parenchymatous substance of the lung, in 
consequence of the resemblance which this lesion 
bears to the extravasation of blood into the sub- 
stance of the brain in cerebral apoplexy. But as 
the name of apoplexy was originally applied to a 
determinate group of symptoms, not to any par- 
ticular form of organic lesion, we evidently divert 
this term from its original signification in thus 
making it synonymous with the effusion of blood 
into the tissue of an organ. However, as the 
term has been sanctioned by the high authority 
of Laennec, and is now generally adopted by 
pathologists, it may be as well to retain it, though 
certainly objectionable, as to encumber our noso- 
logical nomenclature with the term pneu/no 
hemorrhagic!, recently proposed by Andral, as 
more aptly expressing the nature and scat of the 
disease, while it establishes a contrast with the 
term broncho-hemorrhagia, by which he proposes 
to designate the exhalation of blood from the 
lining membrane of the bronchial tubes. 

For a long period, the rupture of a vessel wa* 
the only r;ouice of pulmonary hemorrhage recou- 



156 



APOPLEXY, (PULMONARY) 



nised by pathologists ; and even at the present 
day, the expression of bursting a blood-vessel on 
the lungs is used by many as synonymous with 
Hemoptysis. The cultivation of morbid anatomy 
has, however, tended to correct this as well as 
many other popular errors, and has fully estab- 
lished that, in a large proportion of cases, the 
source of the hemorrhage is to be found in a sim- 
ple exhalation from the lining membrane of the 
bronchia. " I have repeatedly opened," says 
Bichat, " the bodies of persons who died during 
an attack, of hemoptysis, and though I examined 
the surface of their bronchial membrane with the 
greatest care, and even took the precaution of 
allowing it to macerate for some days before 
examining it with a lens, I have never been able 
to detect the slightest appearance of erosion, or of 
the rupture of a vessel." 

Another source of pulmonary hemorrhage has 
still more recently been described by the author 
of the well-known treatise on Mediate Ausculta- 
tion, who states, " that while the greater number 
of slight or moderate hamioptyses consist in a 
simple exhalation of blood from the lining mem- 
brane of the bronchial tubes, the severer cases 
ouginate from a different source, and come chiefly 
from the vesicular structure of the lungs :" and 
this latter is the variety of hemorrhage to which 
he applies the name of pulmonary apoplexy. It 
is true that this affection had been noticed by 
earlier writers, and even described under its pre- 
sent name. Haller, in his Opuscula Pathologica, 
gives a brief and melancholy account of the death 
of a friend, who fell a victim to this disease ; his 
description of the morbid appearances, though 
general, is sufficiently characteristic of the disease: 
" In pulmone utroque, non inflammatio, non ulcus, 
sed sanguinis universalis effusio fuit, ut sudore 
sanguineo in cellulosam fabricam effuso, et sensim 
collecto, nigerrima demum magna pars visuris 
esset." M. Lereille read a memoir on the subject 
before the Academy of Sciences in the year 1816; 
and Doctor Hohntaum published an essay on pul- 
monary apoplexy at Erlangen in 1817. M. Laen- 
nec's treatise was not published until 1819 : 
however, as the affection was entirely unknown 
as a common cause of haemoptysis before the pub- 
lication of his work, and as no preceding writer 
had given its precise anatomical characters, the 
merit of having first accurately described the dis- 
ease must be accorded to Lacnnec, even though 
the more equivocal merit of its denomination may 
be contested by others. 

Apoplexy of the lung, like that of the brain, 
presents considerable variety in the symptoms it 
produces during life, and the anatomical charac- 
ters it presents after death ; for whilst in some in- 
stances it produces no other inconvenience than 
the expectoration of a few ounces of blood, it in 
other cases proves as instantaneously fatal as the 
most violent attack of cerebral apoplexy. Neither 
are its anatomical characters less variable ; for, 
while in its milder form its effects are limited to 
the sanguineous infiltration of the air-cells of one 
or two lobules, it occasionally pours such a deluge 
of blood into the substance of the lung, that the 
delicate structure of the organ is broken down 
oefore it, and even its investing membrane, the 



pleura, is ruptured by the violence of the hemor- 
rhage. 

The anatomical characters of pulmonary apo- 
plexy as described by Lacnnec, arc, a remarkable 
induration of the pulmonary substance, equal to 
that of the completcst hepatization : the indura- 
tion however, is very different from the inflamma- 
tory' affection of the lungs distinguished by this 
term. It is always partial, and rarely ever occu- 
pies a considerable portion of the lungs : its more 
ordinary extent being from one to four cubic 
inches. It is almost always very exactly circum- 
scribed, the induration being as considerable at the 
very point of termination as in the centre. The 
pulmonary tissue around is quite sound and crepi- 
tous, and has no appearance whatever of that pro- 
gressive induration found in pneumonia. The 
substance of the lung is indeed often very pale 
around the hsemoptysical induration ; sometimes, 
however, it is rose-coloured, or even red, as if 
tinged with fresh blood ; but even in this case the 
circumscription of the indurated part is equally 
distinct. The indurated portion is of a very dark 
red, exactly like that of a clot of venous blood. 
When cut into, the surface of the incisions is 
granulated as in a hepatized lung ; but in their 
other characters these two kinds of pulmonic in- 
duration are entirely different. In the second 
degree of hepatization, we can perceive distinctly 
the black pulmonary spots, the blood-vessels, and 
the line cellular intersectures, all of which together 
give to this morbid state the aspect of certain 
kinds of granite. In the induration of haemopty- 
sis, on the contrary, the diseased part appears quite 
homogeneous, being altogether black or of a very 
deep brown, and disclosing nothing of the natural 
texture of the part, except the bronchial tubes and 
the larger blood-vessels. The latter have even 
lost their natural colour, and are stained with 
blood. In scraping the incised surfaces of their 
parts, we can detach a small portion of very dark 
half congealed blood, but in a much less propor- 
tion than we can press out the bloody serum from 
a hepatized lung. We sometimes find two or 
three similar indurations in the same lung, and 
frequently both lungs are affected at the same time. 
(Laennec on Diseases of the Chest, translated by 
Dr. Forbes.) 

Nothing can exceed the accuracy of this de- 
scription, but it only applies to the milder form of 
the disease, when the extravasated blood is effused 
into the air-cells of one or more lobules, and the 
individual survives for a sufficient length of time, 
to have the fluid portion of the extravasation com- 
pletely absorbed. This condition of the lung may 
be termed its hscmoptoic engorgement, to distin- 
guish it from another form of the disease, in which 
the blood, instead of simply accumulating within 
the air-cells, ruptures their delicate parietes, breaks 
down the structure of the lung, and is extravasated 
into the lacerated tissue. It is to this form of the 
disease that the name of pulmonary apoplexy is 
more strictly applicable, as being most analogous 
to the condition of parts which exists in cerebral 
apoplexy. 

This form of the disease seems to differ from 
the hamoptoic engorgement only in degree, the 
laceration of the parenchyma of the lung, and the 



APOPLEXY, (PULMONARY) 



157 



consequent extravasation of blood, being caused 
by the over-distension and rupture of the air-cells, 
from the excessive quantity of blood which is 
poured into them. Accordingly, when the haemop- 
toic engorgement is extensive, or takes place sud- 
denly, and with violence, we generally find its 
interior broken down, and occupied by extrava- 
satcd blood. In a young man who died of organic 
disease of the heart in the Whitworth Chronic 
Hospital, alter experiencing a violent attack of 
hemoptysis about a week before his death, we 
found the lower lobe of the right lung occupied 
by a mass of hremoptoic engorgement as large as 
an orange, and ^mtaining in its centre a clot of 
dark-coloured blood of the size of a hazle-nut ; 
the cavity in which this clot was contained, had 
evidently been formed at the expense of the pul- 
monary parenchyma. Laennec alludes to this 
form of the disease in the passage, where, de- 
scribing the hacmoptoic engorgement, he says, 
"sometimes the centre of these indurated masses 
is soft, and filled with a clot of pure blood." An- 
dral has likewise noticed this variety of the disease 
in his treatise on pathological anatomy. 

In some cases the quantity of blood effused is 
much larger, and a greater extent of the pulmo- 
nary parenchyma is broken down, so that a con- 
siderable portion of the lung is reduced to a soft 
fluctuating mass, in which there can only be dis- 
tinguished some remains of the parenchymatous 
structure of the lung, and a quantity of effused 
blood, partly fluid, and partly coagulated, as in the 
case recorded by Corvisart (Commerdaires sur la 
Trailt de la Percussion) of a young man who 
retired to rest apparently in perfect health, and 
was found dead in his bed the next morning with 
blood streaming from his mouth and nose. On 
dissection, the interior of the right lung was found 
torn and ruptured in every direction, and gorged 
with an enormous quantity of dark-coloured 
blood ; the bronchial tubes were likewise filled 
with the same fluid, as were also the trachea, and 
larynx, the throat, and the posterior nares. As 
examples of such extensive rupture and disorgan- 
ization of the pulmonary parenchyma from extra- 
vasation of blood are of rare occurrence, we shall 
briefly transcribe a case of this description, which 
fell under our notice in the Hardwick Fever Hos- 
pital. A young delicate-looking man in an ad- 
vanced stage of fever stooped out of bed to take 
up his spitting-pot, which had fallen ; while in the 
act of stooping, he became giddy, lost all con- 
sciousness, and fell on the floor ; he remained 
insensible for some minutes, but after throwing up 
a large quantity of blood, he recovered so far as 
to ask for a drink of water ; he drank with 
avidity, and again relapsed into a state of apparent 
insensibility, and died within an hour, discharging 
a quantity of blood from his mouth and nose. On 
dissection, which was made in eighteen hours after 
death, all the air-passages from the mouth to the 
lungs were found filled with dark fluid blood. 
The right lung did not collapse when the chest 
was opened, except its upper lobe, which appeared 
healthy and of its natural colour : the middle and 
lower lobes were externally of a uniform deep red 
colour, and when pressed under the finger con- 
veyed a distinct sense of fluctuation. When cut 
into, a quantity of fluid blood rushed out, bearing 

o 



along with it a number of grumous clots, and 
several masses of broken-down pulmonary tissue. 
The interior of the lung presented a shreddy 
appearance, and resembled a sponge which had 
been steeped to saturation in blood. 

The anatomical characters of this form of pul- 
monary apoplexy differ materially from those de- 
scribed by Laennec. The seat of the disease, 
instead of being circumscribed, solid, and present- 
ing a granular surface, when cut, is perfectly un- 
circumscribed, feels soft and fluctuating to the 
touch, and when cut into, exhibits a mixture of 
fluid and clotted blood infiltrated through the 
parenchyma of the lung, which is ruptured and 
broken down. These differences may, however, 
be satisfactorily accounted for : in the haemoptoic 
engorgement, as described by Laennec, the cir- 
cumscribed, solid, dark-coloured masses, varying 
in size from one to four inches, are evidently 
caused by the infiltration of the blood into the air- 
cells of the part, and its coagulation there ; as any 
one may satisfy himself by examining in the 
strong light of the sun the granular surface, which 
a section of the part exhibits, and by scraping it 
gently with a scalpel, so as to turn out the little 
rounded coagula from the cells in which they are 
moulded, after which the part will exhibit a dis- 
tinct cellular structure, exactly resembling a sec- 
tion of the corpus cavernosum penis. The reason 
of the lesion being in general so accurately cir- 
cumscribed, is, that the cellular tissue which 
invests and isolates each lobule prevents the 
escape of the effused blood into the adjoining 
lobules. The solidity of the part proceeds from 
the serous portion of the blood being absorbed, 
and the fibrinous coagulum becoming intimately 
combined with the tissue of the part; for in those 
cases where death occurs soon after the hemor- 
rhage, the blood is uniformly found in the fluid 
state : and lastly, the dark colour which the hae- 
moptoic induration presents, may be accounted for 
by the stagnation of the extravasated blood, which 
uniformly produces this effect, as in the familiar 
example of an external contusion, and in Hunter's 
well-known experiment of intercepting a portion 
of artery between two ligatures, and finding, after 
a certain time, that the blood thus confined had 
lost its arterial colour, and assumed a dark venous 
hue. In this form of the disease there is no solu- 
tion of continuity, no breaking down of the pul- 
monary tissue, but simply an infiltration of blood 
into the spongy texture of the part. 

But if the texture of the organ is less resisting, 
or the force of the infiltrating fluid more irresisti- 
ble, the pulmonary structure gives way, and the 
interlobular partitions which served to bound the 
progress of the effusion being broken down, it 
ceases to be circumscribed. In this form of the 
disease the blood is seldom wholly coagulated, and 
we believe never so perfectly as in the haemoptoic 
engorgement. For this fact, several satisfactory 
reasons may be assigned. In the first place, when 
the hemorrhage is so violent, death generally fol- 
lows before the blood has had sufficient time to 
coagulate perfectly, and to have its aqueous parts 
absorbed. It generally happens also that those 
extensive hemorrhages are connected with a pecu 
liar liquid state of the circulating fluid, which 
diminishes its tendency tc coagulate, and disposes 



158 



APOPLEXY, (PULMONARY) 



it to pass off more freely by the exhalents, as in 
cases of scurvy, purpura, &c. Besides which, we 
may suppose that blood when effused in a large 
mass is not as favourably circumscribed for having 
its thinner part absorbed, as when minutely sub- 
divided, and each division placed in contact with 
so active an absorbing surface as the walls of the 
air-cells. 

Another variety of pulmonary apoplexy is that 
in which the hemorrhage not only breaks down 
the parenchymatous structure of the lung, but 
likewise ruptures its investing membrane, and 
bursts into the pleural sac. This is by far the 
rarest form of the disease ; we have never seen 
an example of it, nor have we been able to dis- 
cover more than four cases of it on record. 

1. The first is related by Corvisart (op. cit.). 
Dr. Fortassin was found dead in his bed one 
morning after having retired to rest the preceding 
evening in the apparent enjoyment of excellent 
health. On dissection, the right pleural sac was 
found filled with coagulated blood, the interior of 
the right lung was also gorged with it, and its 
surface exhibited several rents, which extended to 
a considerable depth within its substance. In this 
case death occurred suddenly, and was not pre- 
ceded by or accompanied with haemoptysis. 

2. In an analogous case, published by M. Bagh, 
in the. Revue Mudicale, the patient was suddenly 
seized with violent dyspnoea : his face became pale, 
the pulse almost imperceptible, and death super- 
vened in a few minutes after the commencement 
of the attack. 

A quantity of bloody scrum was found effused 
into the left side of the chest, and with it about a 
pint of dark clotted blood, which evidently came 
from a rupture in the base of the lung, the inte- 
rior of which was lacerated and broken down, as 
the substance of the brain is in cerebral apoplexy. 

3. The third example of this form of the dis- 
ease is recorded by Andral, (Clinique Medicale,) 
in the case of a middle-aged man, who presented 
the ordinary symptoms of pulmonary consump- 
tion, attended with a slight degree of dyspnoea. 
One morning he was found breathing with much 
greater difficulty than usual, and his sputa were 
observed to be slightly tinged with blood : during 
the two succeeding days his difficulty of breathing 
increased considerably, the sputa became more 
deeply tinged with blood, and he died in an ex- 
treme state of dyspnoea. On dissection a quantity 
of blood and serum was found in the left pleura, 
the surface of the left lung was ruptured, the size 
of the rupture being about an inch in diameter. 
When the lung was laid open, a space as large 
as an orange was found, corresponding with the 
rent on the surface, and occupied by fragments of 
torn pulmonary tissue, mixed up with adarkgru- 
mous blood. 

4. The fourth and last case of this description 
on record is that recently published by Dr. J. 0. 
Ferguson, in the first volume of the Dublin Medi- 
cal Transactions. A robust man, set. 3G, who 
had occasionally suffered from attacks of consti- 
pation and bronchitis, complained, on the 19th of 
June, 1829, that his cough was increased, his 
chest somewhat oppressed, and his expectoration, 
oince the day preceding, slightly tinged with blood ; 
his countenance was pale, his pulse about 90, and 



feeble and his skin covered with a cold c.ammy 
perspiration. On the next day he felt relieved by 
the operation of a purgative. Dunng the suc- 
ceeding night he was rather restless ; however he 
ate his°brcakfast as usual, and while in the act of 
stooping to put on his shoes, he complained to 
his wife of loss of vision, seemed to faint, and 
died without a struggle. Examination made forty- 
eight hours after death : — the left pleural sac con- 
tamed about three quarts of blood, the scrum su- 
pernatant, as in blood allowed to stand after vene- 
section, and the clot in considerable quantity, but 
very soft, occupying the most dependent portion 
of the cavity. The lung had contracted no adhe- 
sion ; the superior lobe was one mass of the most 
perfect pulmonary apoplexy, the structure of the 
lung seeming to be actually broken up by the ex- 
cessive effusion of blood into it ; the apoplectic 
mass was soft and flabby ; it would scarcely bear 
to be incised, but broke down easily under the 
finger or scalpel. On the superior and posterior 
part of the affected lobe a laceration of the invest- 
ing pleura was found, about one inch in length 
and half an inch in breadth, with very irregular 
edges, and immediately over the point where the 
sanguineous effusion into the substance of the 
lung seemed most intense, and where we might 
naturally expect the greatest violence to be oppos- 
ed to its serous covering. A remarkable fact in 
the history of this case was, that he had expecto- 
rated no blood for fourteen hours before death, nor 
in the agony was there any escape of blood from 
the mouth or nares which might lead to a suspi- 
cion of the real seat of the disease. The same 
remark is also applicable to the preceding cases, 
Nos. 1 and 2, in which no haemoptysis whatever 
took place before death, and the cause of the fatal 
catastrophe was only discovered on dissection. 

The etiology of this disease is still involved in 
considerable obscurity. In fact, we know as little 
of the peculiar modification which the texture of 
the lung undergoes when it allows the blood deter- 
mined towards it to escape from its vessels, as we 
do of the changes which these vessels undergo 
when at one time they secrete pus, and at another 
exhale a thin serous fluid. Andral supposes that 
pulmonary apoplexy differs from bronchial hemor- 
rhage only in its situation, the former being caused 
by exhalation from the lining membrane of the 
air-cells, as the latter is by exhalation from the 
lining membrane of the bronchia ; in fact, he sup- 
poses that pulmonary apoplexy is to bronchial he- 
morrhage what pneumonia is to bronchitis, — a 
similar disease affecting the ultimate ramifications 
of the bronchia instead of their primary divisions. 
He is likewise of opinion that in a large propor- 
tion of cases the morbid alteration to which the 
name of pulmonary apoplexy is applied, should 
not be regarded as the only source of all the blood 
which had been expectorated during life ; on the 
contrary, he believes that the hemorrhage gene- 
rally proceeds from a much larger surface of the 
mucous membrane, and that the dark indurated 
patches of pulmonary apoplexy arc caused by tht 
blood accumulating in those points whilst it \va^ 
removed from the other parts of the bleeding sur- 
face, and expectorated as fast as it was effused 
there. By adopting this view of the subject, we 
are enabled to understand those cases of violent 



APOPLEXY, (PULMONARY) 



159 



and profuse hamoptysis, in which, after death, the 
extent of the hamioptoic engorgement is found 
very small, and not at all commensurate with the 
quantity of blood which had been expectorated 
during life. The quantity of blood discharged in 
this way is sometimes so very great, that Laennec 
conceived it impossible to account for it without 
admitting that the blood in such cases experiences 
a sudden dilatation. This speculation, however, 
as well as other theories respecting the state of the 
blood and its capillary vessels in hemorrhage, will 
be with more propriety discussed in the general 
article on that subject See Hemorrhage. 

The occasional causes of pulmonary apoplexy 
are, in general, the same as those of hemorrhage 
from the bronchia. (See Hjemopttsis.) It is 
to be remarked, however, that the spitting of blood 
which accompanies the formation of tubercles, is 
most frequently of the latter species ; while that 
which occurs in subjects affected with organic dis- 
ease of the heart is most commonly of the former 
kind : the suppression of habitual discharges, such 
as the menses, hemorrhoids, or epistaxis, may give 
occasion to both kinds indifferently. Plethora — 
the sudden or long-continued impression of exces- 
sive heat or cold, ought also to be mentioned 
among the occasional causes of this, as of many 
other diseases of a very different kind ; but in 
most instances such causes would not of them- 
selves have been sufficient to produce the disorder, 
without some peculiarity of constitution in the 
individuals. (Laennec, op. cit.) 

Of all these, organic disease of the heart is de- 
cidedly the most common. Of twenty-two cases 
of pulmonary apoplexy that we have examined 
after death, fifteen, or rather more than two-thirds 
of the whole, occurred in individuals labouring 
under heart disease ; in two instances only was 
the pulmonary apoplexy connected with tubercles 
in the lungs ; in one individual the disease was 
caused by external injury ; in four cases we were 
unable to trace the hemorrhage to any local im- 
pediment to the circulation, or to any organic dis- 
ease either of the heart or lungs. Andral like- 
wise states, as the result of his experience, that 
organic disease of the heart is decidedly the most 
common cause of pulmonary apoplexy : (op. cit.) 
Cruveilhier relates two cases of pulmonary apo 
plexy, (Did. de Medecine, &c.,) both of which 
were connected with organic disease of the heart. 
Of two cases recorded by Bouillaud in the Ar- 
chives Generates, one was connected with disease 
of the heart, the other with hepatization of the 
lung. Mr. Burns, in his work on Diseases of the 
Heart, has also noticed the frequent connexion 
between these diseases. " The pulmonic vessels," 
says he, (page 53,) " by the congestion and con- 
tinued vis-a-tcrgo, are ruptured, blood is forced 
into the air-cells, or, if urged still further, all the 
cellular structure of the lungs is crammed with 
blood : these organs cut like liver, and sink when 
put into water." Bertin, likewise, in his " Truite 
dea Maladies du Caw" particularly notices the 
influence of certain diseases of the heart in pro- 
ducing pulmonary apoplexy. According to this 
author, hypertrophy of the right ventricle has the 
same tendency to produce apoplexy of the lung, 
that hypertrophy of the left has to cause apoplexy 
of the brain, and by the same mechanism ; for as 



the brain directly receives the shock of the column 
of blood which is propelled by the aorta through 
the left ventricle, so the lungs receive directly the 
shock of blood which is propelled through the pul- 
monary artery by the right ventricle. According- 
ly, when the parietcs of the right ventricle acquire 
an increased volume and proportionate increase 
of energy in their contractions, the blood is pro- 
pelled through the pulmonary vessels with such 
an increased degree of force as is sometimes suffi- 
cient to over-distend and rupture their parietes. 
The hemorrhage produced in this way he consid- 
ers to be of an active character, and essentially 
different from the passive hemorrhage which re- 
sults from the over-distension and rupture of the 
pulmonary capillaries, arising from the mechanical 
congestion of the lung caused by narrowing of 
the left auriculo-ventricular orifice. Of all dis- 
eases of the heart, these have the strongest ten- 
dency to produce attacks of pulmonary apoplexy, 
in consequence of the direct influence they exert 
over the pulmonary circulation ; but the same 
effect may likewise be produced by any disease of 
this organ which obstructs the free transmission 
of the blood. We have seen two cases of pul- 
monary apoplexy connected with hypertrophy of 
the left and passive dilatation of the right ventricle. 
In a great majority of cases the occurrence of 
pulmonary apoplexy may no doubt be traced to 
the agency of some of the causes just enumerat- 
ed, and may therefore be considered as a second- 
ary or symptomatic affection. But there are like- 
wise cases of this disease, in which the cause ot 
the determination of blood to the lungs, and its 
escape from the capillary vessels, is not preceded 
by any marked derangement in the pulmonary 
circulation or other premonitory symptom, and 
must therefore, in the present state of our know- 
ledge, be regarded as a primary or idiopathic dis- 
ease, though in all probability it is only the mani- 
festation of some more general or constitutional 
derangement, particularly in those cases where 
apoplectic extravasations are formed in several 
organs at the same moment, as in the head, liver, 
and lungs, (Andral,) and in the case alluded to 
by Laennec, where he found large extravasations 
of blood in the cellular membrane of every limb, 
of the trunk, and of the greater number of the 
abdominal viscera. How far it may, in such cases, 
depend on a morbid alteration of the fluids, or oh 
some disease of the nervous or vascular system, 
it is not our province at present to inquire, as 
these considerations will find their place in the 
general article on hemorrhage. Certain, however, 
it is, that many cases of pulmonary apoplexy oc- 
cur, which cannot be referred to any of the occa- 
sional causes enumerated by authors : indeed, the 
greater number of these overwhelming apoplexies, 
apoplexies foudroyantes of the French, are of 
this class. Of the six cases of apoplexy proving 
suddenly fatal, recorded in this article, three were 
in the enjoyment of perfect health up to the mo- 
ment of the apoplectic seizure ; a fourth, described 
as occurring in a robust man in the prime of life, 
had occasionally Buffered from attacks of bron- 
chitis and constipation ; a fifth was in an advanced 
stage of typhus fever ; and in one case only could 
the hemorrhage be referred to any organic JisMisw 
of the thoracic viscera. 



160 



APOPLEXY', (PULMONARY) 



The diagnosis of pulmonary apoplexy is. in 
many cases, a matter of considerable difficulty. 
When the patient dies suddenly without hemopty- 
sis, as in cases No. 1 and 2 already recorded, it 
will often be impossible to determine, except by 
inspection, whether death was caused by cerebral 
or pulmonary apoplexy, or by rupture of the 
heart : and even in those cases where the fatal 
attack is accompanied with haemoptysis, the phy- 
sician will sometimes find considerable difficulty 
in ascertaining the source of the hemorrhage, as 
the bursting of an aneurismal sac into the bron- 
chia may produce effects precisely similar. In the 
more common and less violent forms of the dis- 
ease, in which an accurate diagnosis is of much 
more practical importance, the symptoms most 
pathognomonic, as enumerated by Laennec, are, 
violent sense of oppression in the chest ; great 
difficulty of breathing ; cough, accompanied with 
irritation of the larynx, and sometimes by very 
acute pain of the chest ; expectoration of bright 
and frothy, or black and clotted blood, quite pure, 
or mixed with salivaor mucus ; frequent full pulse, 
with a particular kind of vibration even when soft 
or weak, as it frequently is after a day or two. 
There is rarely any positive fever, and the heat of 
the skin continues natural, or nearly so ; frequent- 
ly the heart and arteries yield the bellows-sound 
to a very marked degree. Of all these symptoms 
the spitting of blood is the most constant and 
most severe, and returns by fits, accompanied with 
cough, oppression, anxiety, intense redness or ex- 
treme paleness of the face, and coldness of the 
extremities. When the hemorrhage is very great, 
it comes on sometimes with a very moderate de- 
gree of cough, accompanied by a convulsive ele- 
vation of the diaphragm, like that which takes 
place in vomiting. (Op. cit.) 

But of all this assemblage of symptoms, there 
is not one, not even the haemoptysis, which is con- 
stantly present ; and they may all occur conjoint- 
ly without necessarily inferring the existence of 
pulmonary apoplexy. Haemoptysis is decidedly 
the most constant, and when very copious, the 
least equivocal symptom ; but there are abundant 
instances of pulmonary apoplexy occurring and 
even proving fatal with only slight haemoptysis, 
or even without any expectoration of blood, and 
likewise of profuse haemoptysis without any apo- 
plectic extravasation. Laennec observes that the 
slighter cases of haemoptysis depend upon a sim- 
ple exhalation from the bronchia, but that those 
cases of violent and extreme hemorrhage which 
often resist all medical treatment, almost invari- 
ably proceed from the vesicular structure of the 
lung. This distinction will be found generally 
correct, but still the quantity of the haemoptysis 
cannot be taken as a certain index of the seat of 
the disease ; for the same author observes that, 
when the haemoptoic engorgement is limited to 
the extent of one or two square inches, the affec- 
tion may be latent and unaccompanied with any 
spitting of blood. We have seen four cases of 
this kind in which no blood had been expectorated 
during life, and it was only on dissection that the 
existence of haemoptoic engorgement was dis- 
covered. Andral has likewise seen several cases 
)f pulmonary apoplexy, in which the quantity of 
elood expectorated did not exceed a table-spoon 



full at a time ; and in the more aggravated forms 
of the disease, death is occasionally produced 
before a single drop of blood has been expecto- 
rated, as has been already proved by several ex- 
amples cited in a preceding part of this article 
On the other hand, the most profuse hemoptysis 
may take place from the bursting of an aneuris- 
mal sac, from the rupture of a large vessel in a 
tuberculous abscess, or by simple exhalation from 
the mucous membrane of the bronchia. The 
quantity of blood expectorated can therefore only 
afford presumptive evidence of pulmonary apo- 
plexy i in order to ascertain positively its exist- 
ence, we must have recourse to the signs furnish- 
ed by auscultation and percussion. These signs 
are dulness of sound in that part of the chest 
which corresponds with the seat of the disease, 
and the total absence of all respiratory murmur in 
the same circumscribed space, together with a 
crepitating rale around this space ; this rale, which 
here indicates a slight infiltration of blood, is al- 
ways found at the commencement of the disease, 
but is frequently wanting in the latter stages. 
When these signs co-exist with pulmonary he- 
morrhage, we may be assured that the seat of the 
hemorrhage is in the substance of the lung, and 
not simply in the bronchia. Besides these, which 
may be considered as the pathognomonic signs of 
pulmonary apoplexy, there is likewise, especially 
at the root of the lungs where the larger bronchia 
are situated, a mucous rale with bubbles, which 
seem to be large and thin, and formed by a matter 
more liquid than mucus ; they also burst more 
frequently, and with a peculiarity of sound which 
cannot be mistaken. As the most common seat 
of this disease is in the central parts of the lower 
lobe, or towards the middle and posterior part of 
the lungs, it is consequently on the posterior anil 
inferior part of the chest, that we ought to search 
for them with the stethoscope. (Laennec, up 
cit.) 

The rationale of these signs is sufficientl) 
obvious ; the dulness of sound and extinction ol 
the respiratory murmur are caused by the san 
guineous infiltration of the spongy texture of th« 
part preventing the ingress of air, and converting 
its porous texture into a dense solid suostance 
The crepitating rale in the immediate vicinity of 
the haemoptoic engorgement in all probability arise* 
from the bursting of the air-bubbles a=> they pass 
through the uncoagulated blood contained in the 
adjoining air-cells, as the bubbling or mucous rale 
results from the bursting of the larger bullae in 
the bronchia. 

If these physical signs could uniformly be de- 
tected in every case of the disease, the diagnosis 
of pulmonary apoplexy would be sufficiently sim- 
ple ; for the haemoptysis and general history of 
the case would serve to distinguish it from any of 
those diseases which exhibit the same stethoscopic 
phenomena, such as lobular pneumonia or clus- 
tered tubercles. It is evident, however, that nei- 
ther the dulness of sound nor the absence of 
respiratory murmur can be detected when the 
haemoptoic engorgement is of small extent, espe- 
cially if situated, as it often is, in a central part 
of the lung, or in that portion of the organ which 
rests upon the diaphragm ; for the healthy pul- 
monary tissue interposed between the seat of the 



APOPLEXY, (PULMONARY) 



161 



disease and the parietes of the chest, must effec- 
tually mark the morbid sounds. For this reason 
the stethoscope rarely affords any positive infor- 
mation in those cases of pulmonary apoplexy, 
where the haemoptoic engorgement is confined to 
a few isolated spots, and even in more extensive 
cases of haemoptysis it too often fails to point out 
the precise source of the hemorrhage. In several 
cases of violent and copious haemoptysis, when, 
from the extreme state of dyspnoea and great con- 
stitutional disturbance, we had every reason to 
suspect the existence of an haemoptoic engorge- 
ment, we have found the sound on percussion not 
perceptibly altered, and have been unable to detect 
any other stethoscopic evidence of the disease 
than a loud mucous rale, which only served to 
indicate the presence of blood in the bronchia, 
but afforded no information as to the source from 
whence it came. The same difficulty of deter- 
mining in certain cases whether haemoptysis pro- 
ceeds from bronchial hemorrhage or from pulmo- 
nary apoplexy, has likewise been experienced by 
many other persons well versed in the use of the 
stethoscope. M. Cruveilhier even goes so far as 
to say that no information is to be obtained from 
auscultation in such a case — " Quant a l'auscul- 
tation et a la percussion clles nc m'ont rien ap- 
pris." {Dictionnaire cle Medecine, <^c.) In this 
opinion, however, we can by no means coincide ; 
for by the aid of the physical signs laid down by 
M. Laennec, we have been enabled, in several 
instances, to ascertain with precision the nature 
and extent of the haemoptoic engorgement. 

The danger to be apprehended from pulmonary 
apoplexy, must, as in other forms of haemoptysis, 
depend in a great measure on the cause of the 
hemorrhage, the quantity of blood lost, and the 
previous state of the patient's health. (See 

HAEMOPTYSIS.) 

When the hemorrhage supervenes during the 
course of an organic affection of the thoracic 
viscera, such as disease of thr> heart, or the de- 
velopement of tubercles in the lungs, the nature 
of that affection must of course be taken into 
consideration in forming our estimate of the pro- 
bable result : in like manner, when it occurs as a 
vicarious discharge, or as the effect of violent 
exertion, general plethora, or any other appre- 
ciable cause, the prognosis must depend materially 
on the nature of such cause, and the power we 
3 of removing or controlling it, so that it 
shall not again produce a repetition of the he- 
morrhage. 

But, in all cases of pulmonary apoplexy, the 
prognosis should, ceteris paribus, be more guard- 
ed than in those forms of haemoptysis, where the 
hemorrhage proceeds from the bronchia, and the 
blood is removed from the lungs as fast as it is 
effused j whereas in pulmonary apoplexy, the 
blood accumulates in the parenchymatous sub- 
stance of the lung, and often renders a consider- 
able extent oi' that essential organ unfitted for the 
purpose of respiration : besides which, the blood 
effused into the air-cells may in some degree be 
regarded as a foreign body capable of producing 
various morbid alterations. 

Laennec states that resolution of the haemop- 
'iiic. engorgement takes place with considerable 

Vol. I. — 21 o* 



facility, whatever may be the severity of the dis- 
ease. In those instances where he had an oppor- 
tunity of tracing the progress of this resolution 
by dissection, he found that the indurated parts 
passed successively from dark red to brown or 
pale red, and that, in proportion as the colour 
faded, the parts lost their granular texture and 
density. When the resolution is complete, it 
leaves no trace of the disease in the pulmonary 
substance : (op. cit.) This favourable termination 
of the disease may be known during life, by the 
progressive improvement which takes place in the 
patient's respiration and general health, by the 
sound or percussion becoming gradually clearer 
as the resolution advances, and by the crepitating 
rale becoming audible over the surface of the 
haemoptoic engorgement : it is not, however, so 
constantly audible in this disease as during the 
resolution of pneumonia. In a few cases of pul- 
monary apoplexy where we had an opportunity 
of watching the progress of the resolution, we 
were unable to detect either the crepitating or 
sub-crepitating rale, but the sound on percus- 
sion became gradually clearer, and the respiration, 
which was at first extremely faint, slowly returned 
to its natural state. M. Boillaud records a case — 
a solitary instance we believe — in which a clot of 
pulmonary apoplexy was found surrounded by a 
well organized cyst, precisely similar to those 
which are occasionally developed round apoplectic 
extravasations in the brain, and which, like them, 
was probably destined to become an agent of ab- 
sorption. (Observations pour servir a I'histoire 
d'apoplexie pulmonaire par M. J. Bouillaud.") 

Besides these, which may be regarded as the 
favourable terminations of haemoptoic engorge- 
ment, others of a less favourable nature have also 
been described by pathologists. Thus, according 
to Andral, " It sometimes happens that the blood 
extravasated into the lung, instead of being ab- 
sorbed, has a tendency to acquire a right of settle- 
ment there by becoming organized, and thus ren- 
dered capable of performing the different acts of 
nutrition and secretion ;" in this state it may be- 
come a nidus for the developement of different 
morbid productions, such as tubercle, melanosis, 
pus, &c. We are disposed to think, however, 
that the developement of tubercles can seldom be 
traced to this source, as in eighty-six cases of 
phthisis, of the dissections of which we have kept 
pretty accurate notes, we only find mention made 
of an haemoptoic engorgement having been found 
in two individuals ; and even in these instances it 
is just as probable that the tubercles may have 
caused the apoplectic extravasations, or that both 
may have been effects produced by a common 
cause. Laennec likewise observes, (op. cit.) that 
the haemoptysis which precedes or accompanies 
the symptoms of confirmed consumption, arises 
much more frequently from bronchial hemorrhage 
than from pulmonary apoplexy ; and the accuracy 
of this observation has been confirmed by Louis 
and Andral. 

The suppuration of the apoplectic mass, and lUi 
evacuation by the bronchia, have been enumerated 
by M. Cruveilhier (op. cit.) among the termina- 
tions of this disease. As, however, this opinion 
is not supported by observation, and is directly 
contradicted by Broussais {Phlegmasia Ckro- 



162 



APOPLEXY, (PULMONARY) 



niqucs), we may conclude that its occurrence is 
exceedingly rare, if indeed it ever takes place. 

Lastly, pulmonary apoplexy 1ms been observed 
to occur as a precursory symptom of gangrene, 
and may, we conceive, in some eases contribute to 
produce it. In one instance particularly we were 
enabled to follow the different stages of the dis- 
ease from the formation of an extensive hamioptoic 
engorgement to its conversion into a large gan- 
grenous abscess. 

The rationale of this transition may, we con- 
ceive, be explained thus : in the hxmoptoic en- 
gorgement the circulation through the indurated 
mass is- completely obstructed by the solidification 
of the part, and by the vessels leading to it being 
plugged up with coagula of fibrine. This plug- 
ging up of the vessels has been noticed by Laen- 
nec, and more particularly by Bouillaud, (op. cit.) 
and we have repeatedly ascertained the fact on 
dissection. Now if we compare the condition of 
the part thus circumstanced with the pathology 
of gangrene as laid down by the most recent and 
approved authorities on the subject, we shall find 
it placed under precisely the most favourable cir- 
cumstances for passing into gangrene, or, as the 
disease has been more appropriately designated by 
Dr. Low, putrefactive disorganization of the 
lung. 

"I have already shown," says M. Andral, 
(Treatise on Pathological Anatomy, translated by 
Dr. Townsend, page 513,) " that gangrene is not 
necessarily preceded by any violent degree of 
irritation, but may be produced by any cause 
which retains the blood in the capillaries of the 
part, especially if by such stagnation the arrival 
of fresh blood by the arteries is prevented. In 
some persons the slightest stagnation of the blood 
has a remarkable tendency to be followed by gan- 
grene of the part : this disposition to gangrene, 
which in these persons is constitutional, may he 
produced in others by a variety of causes ; and in 
Cruveilhier's folio work on morbid anatomy we 
read the following account of the pathology of 
gangrene: — "Gangrene is a morbid condition 
which may occur primitively in any tissue of the 
body, or consecutively in any organic disease, such 
as inflammation, cancer, tubercle, &c. In fact it 
always supervenes whenever the course of the 
blood is intercepted either by a mechanical obsta- 
cle, or by the obstruction of the principal a/id 
collateral arteries or veins." (Anatomie Patho- 
logique du corps humain, 3/ne livraison.') 

The consideration of this subject will be more 
fully resumed in the article gangrene : we have 
only alluded to it at present, because, if we admit 
the possibility of gangrene supervening on a 
hsemoptoic engorgement, our prognosis must al- 
ways contemplate the possibility of such an event, 
especially when the engorgement is extensive, and 
occurs in those conditions of the constitution which 
have been observed to be most favourable to the 
tormation of gangrene. 

The treatment of this disease must of course be 
regulated, in a great degree, by the age, constitu- 
tion of the patient, and the quantity of blood 
already lost ; the cause of the hemorrhage must 
likewise be taken into consideration, in order that 
the treatment may be adapted to the nature of the 
disease, and not to the name it bears. The mea- 



sures pursued for the cure of pulmonary apoplexy 
when connected with purpura, or scurvy, must 
differ very materially from those which are em- 
ployed when it proceeds from plethora, or hyper- 
trophy of the heart. 

As a general rule, however, it may be laid down, 
that the principal indications to be fulfilled in the 
treatment of this disease, are to arrest the further 
progress of the hemorrhage by the prompt employ- 
ment of such measures as are best calculated to 
reduce plethora, moderate the action of the heart 
and arteries, and change the determination of 
blood, and in the next place, to prevent a recur- 
rence of the hemorrhage by removing, or where 
that is impracticable, controlling those causes 
which may in any way tend to reproduce it, as, 
by re-establishing any habitual discharges, whose 
suppression may have led to the vicarious hemor- 
rhar«?, or by removing, or at least palliating any 
organic disease, or constitutional disturbance with 
which the hemorrhage might have been originally 
connected. The diseases both local and constitu- 
tional with which pulmonary apoplexy is usually 
connected have been already enumerated among 
the causes of this affection ; it is therefore unne- 
cessary to repeat them here: the treatment adapted 
to each will be detailed in their respective articles. 

As we shall have occasion, when treating of 
haemoptysis, to enter fully into the consideration 
of the different remedial agents that have been 
found most efficacious in suppressing pulmonary 
hemorrhage, we shall, in order to avoid repetition, 
refer the reader to the article on that subject, only 
remarking that, as the hemorrhage is in general 
much more profuse in this variety of the disease 
than in bronchial hemorrhage, and as the accumu- 
lation of blood in the parenchymatous structure 
of the lung is always attended with considerable 
danger and distress, and the resolution of the in- 
durated part at best a slow and uncertain process, 
our treatment should be proportionally prompt and 
decisive. With this view it is advisable to open 
a vein largely, and draw blood freely, at the very 
onset of the disease. The application of leeches 
has generally been found a very inefficient substi- 
tute for the free use of the lancet. Dr. James 
Clark states that, in plethoric individuals threat- 
ened with apoplexy or haemoptysis, the applica- 
tion of leeches frequently decides the very occur- 
rence of the disease it was intended to prevent ■ 
(note to Dr. Porbes's translation of Luennec.) 
A very small bleeding from a vein may also, as 
Laennec observes, produce the same effect : ac- 
cording to this author, one bleeding of twenty oi 
twenty-four ounces on the first or second day will 
have more effect in cheeking the hemorrhage thin 
several pounds taken away in the course of a fort- 
night. It is even beneficial in general to induce 
partial syncope by means of the first bleeding; and 
he adds that in cases of this kind the fear of ex- 
hausting the patient's strength is without grounds, 
since we know that the most copious venesection 
falls short of the loss of blood sustained from pul- 
monary hemorrhage in young and robust subjects 
even in the course of a few minutes ; while the 
debilitating effect of the hemorrhage is infinitely 
greater than the loss of blood produced by the 
lancet. Should the hemorrhage continue after 
the pulse has become small and weak, and the 



APOPLEXY, (PULMONARY) — ARTERITIS, 



163 



strength much reduced, it will not be prudent to 
employ further venesection, but to have recourse 
to derivatives, among which purgatives are un- 
questionably the most efficacious. A drastic ene- 
ma or cathartic frequently checks the hemorrhage, 
and e\en the hemorrhagic molirnen, especially if 
they are productive of faintness. Nauseating 
doses of tartar emetic have likewise been found 
beneficial in controlling the circulation. The 
acetate of lead, too, has been highly extolled in 
this disease for its sedative and styptic qualities. 
Dr. Mackintosh states that he has seen it, when 
administered in full doses, act in the most wonder- 
ful manner in suppressing even those hemorrhages 
which were afterwards proved by dissection to 
have proceeded from a ruptured blood-vessel in the 
lung, (Mackintosh's Practice of Physic ,) and he 
strongly recommends it in those cases of pulmo- 
nary apoplexy where the patient has lost too much 
blood before we are called, or where the hemor- 
rhage continues after sufficient bleeding. Prussic 
acid will also be found useful in controlling the 
inordinate action of the heart and arteries, which 
not unfrequently subsists after much blood has 
been lost, and likewise in allaying the teazing 
cough and irritation in the throat, which are some- 
times very troublesome in this disease. We have 
likewise found digitalis useful in this way, parti- 
cularly in those cases where the pulmonary affec- 
tion was connected with diseases of the heart. It 
is scarcely necessary to add that the antiphlogistic 
regimen must be strictly enforced, and that rest, 
silence, and cool air are indispensable. 

R. TOWNSEND. 

[APPENDIX VERMIFORMIS C^CI, in- 
flammation of tiif.. See Enteritis.] 

ARTERITIS. Much difference of opinion has 
subsisted amongst authors respecting inflamma- 
tion as occurring in the interior of the heart and 
arteries. Some, amongst whom Laennec holds 
the most distinguished place, have thought it 
extremely rare ; others have attributed to it nearly 
all the morbid appearances and changes that are 
found in those parts. It will be convenient to 
consider the subject under the separate heads of 
acute and of chronic arteritis, ranging under each 
its proper anatomical characters, and the morbid 
alterations that appear to belong to it. 

Acute arteritis. 

The anatomical characters of acute arteritis are, 
redness of the internal membrane of the heart 
and arteries, an effusion of plastic, pseudo-mem- 
branous lymph on its surface, and thickening and 
ulceration of its substance. Each of these charac- 
ters will be considered in succession. 

Redness of the internal membrane of the heart 
and arteries. — This is sometimes inflammatory, 
and sometimes not. The redness not inflamma- 
tory often appears in the aorta, the pulmonary 
artery, and the heart, and is a uniform intense 
colour, as if stained by the blood. Corvisart avows 
that he cannot give a satisfactory account of its 
nature and cause. (Corvisart, p. 36.) P. Frank 
regarded it as an inflammation of the arteries, 
which, according to him, occasions a peculiar and 
almost always fatal fever. (De Curand. Homin. 
Morbis, torn. ii. p. 173.) Bertin and Bouillaud 
have considered it, whatever was its shade, as the 



result of inflammation. (Traite, &c p. 55.) 
Laennec entertains an opposite opinion and de- 
monstrates satisfactorily that the redness in ques- 
tion, when not accompanied by other anatomical 
characters of inflammation, is the result of san- 
guineous imbibition. This opinion has been con- 
firmed by the discoveries of Dutrochet.* 

As it is necessary that the reader be able to 
judge for himself, we shall give some account of 
this redness, adhering to the description of Laen- 
nec, which we have verified by repeated experi- 
ments and dissections. 

The redness is sometimes scarlet, and sometimes 
brown or violet. The scarlet redness of the inte- 
rior of the arteries is often confined to the internal 
membrane exclusively ; and, when that mem- 
brane is removed by scraping with the scalpel, the 
fibrous coat is found underneath as pale as in its 
natural state. But in other cases the redness 
penetrates more or less deeply into the fibrous 
coat, and sometimes reaches, in parts, even the 
cellular or external tunic. The redness of the 
internal coat is a perfectly uniform tint, similar to 
that which would be presented by a piece of 
parchment painted red. No trace of injected 
capillaries can be distinguished in it, but the tint 
is sometimes deeper in one part than another. 
Sometimes it diminishes insensibly from the ori- 
gin of the aorta to the place where the redness 
ceases ; but very often it terminates suddenly, and 
by forming abrupt borders of an irregular shape. 
Sometimes, in the midst of an intensely red por- 
tion, is found an accurately circumscribed patch 
of white, which produces precisely the effect that 
is occasioned by an impression of the finger on a 
part of the skin affected with phlegmon or ery- 
sipelas. When the aorta contains very little 
blood, the redness only exists in the tract in con- 
tact with it, and forms a sort of ribbon. The ori- 
gin and arch of the aorta are the parts of that 
artery which are the most frequently found thus 
reddened. Sometimes nearly all the arteries pre- 
sent the stain. The aortic and mitral valves then 
participate in it, and appear as if they had been 
plunged in a red dye. Though the red is scarlet 
in the arteries, it is deeper on the valves, approxi- 
mating slightly to purple or violet. When the 
pulmonary artery is reddened, its valves and the 
tricuspid are also very commonly stained in the 
same way. The stain of the right cavities and 
vessels of the heart is a. ways of a deeper and 
browner hue than that of the left ; a circumstance 
dependent, in all probability, on the darker colour 
of the venous blood. The internal membrane of 
the ventricles and auricles sometimes does not 
present any sensible change of colour, even when 
the valves are the most deeply reddened. Still, it 
is not rare for the internal membrane of the 
auricles to participate in the redness, and in this 
case its tint resembles that of the valves. Mori, 
rarely, the surface of the ventricles also presents a 
similar redness, but ordinarily it is browner or 
more violet. Sometimes the internal surfaces of 
the ventricles and auricles are the only parts red- 
dened ; but this never occurs except when the 
heart is gorged of blood, and the arteries contain 
scarcely any. The redness above described is not 

* Dutrochet, Nouvelles Recherches sur I'Eridosmoso et 
PEjcosmose. Paris, lrtif. 



164 



ARTERITIS, 



accompanied wi h any sensible thickening or 
vascular injection of the stained membranes. A 
few hours* maceration in water suffices to make it 
totally disappear. 

Such are the characters of the scarlet redness. 
We next come to the brownish or violet stain. It 
is found equally on the aorta, the pulmonary 
artery, the valves, the auricles, and the ventricles. 
Most commonly, indeed, it is observed in all these 
parts at once. It is often very unequal in inten- 
sity, and is always more marked on the parts of 
the vessels that, according to the laws of gravity, 
have been most in contact with the blood. It is 
not so commonly restricted to the lining membrane 
as the scarlet redness ; for the muscular substance 
of the auricles and ventricles, and even the fibrous 
tunic of the aorta and pulmonary artery participate 
in the dye ; at least, in some points, and to a cer- 
tain depth. 

Such is Laennec's account of redness of the in- 
ternal membrane. But redness, he contends with 
great justice, is not sufficient to characterise in- 
flammation, particularly when it is not accompa- 
nied by thickening or vascular injection of the 
reddened parts. Moreover, the exact circumscrip- 
tion of the redness in some cases, and its abrupt 
termination by geometrical though irregular lines 
— an appearance never seen in inflammation of 
serous membranes, though it is occasionally and 
to a slight degree in that of mucous* — banish the 
idea of inflammation, and rather convey that of a 
stain by a coloured liquid which had run irregu- 
larly on the reddened membrane, or which, on ac- 
count of its deficient quantity, had not been able 
to touch every part. Again, the circumstances 
under which the redness is usually found, coun- 
tenance the idea of its being a stain rather than 
from inflammation. 

Laennec has found the scarlet red to occur after 
a somewhat protracted agony in subjects still vigo- 
rous, but yet cachectic, in consequence of disease 
of the heart or otherwise. The blood in these 
cases was never very firmly coagulated, and the 
body most frequently presented some signs of de- 
composition. The brownish or violet red he found 
in those subjects especially who had died of con- 
tinued typhoid fevers, of emphysema of the lungs, 
or of disease of the heart. Almost all had expe- 
rienced a long and suffocative agony ; in all, the 
blood was very liquid and evidently altered, and 
signs of premature decomposition existed in the 
bodies. We have found it also very constantly in 
cachectic subjects affected with passive hemorrhage 
from the gums, from ulcers, &c. as in scurvy. It 
is moreover, in summer particularly, and in sub- 
jects that are opened more than twenty-four 
hours after death, that the dark discoloration is 
most frequently met with. Both varieties of red- 
ness, and particularly the brownish or violet, are 
accompanied with a ereater or iess degree of soft- 
ening of the heart, and with an increased humidity 
of the arterial walls. In most instances these 
states are evidently the fleets of a commencement 
of putrefaction. Laennec has strong doubts whe- 
ther the scarlet redness ever produces symptoms 
sufficiently severe and constant to render it capa- 
ble of being recognised. He has found it in sub- 

♦ We have scon jt in the trachea in variola. See also 
Bro'onneau on Diphtherite. 



jects who had died of widely different complaints, 
and he was never able to predict it by any con- 
stant sign. 

The cases which Bcrtin and Bouillaud have 
adduced in substantiation of their opinion, that 
the redness in question is of an inflammatory na- 
ture, are strikingly corroborative of the views of 
Laennec. For, of twenty-four cases, eleven are 
typhoid fever, or other affections in which there 
was a manifest alteration of the liquids, and pre- 
mature putrefaction. The thirteen other cases 
consist almost entirely of consumptive patients ; 
and the writers observe, in general terms, that the 
redness appeared to coincide with a remarkable 
fluid state of the blood. It must further be re- 
marked, that most of their examinations were 
made in summer, and more than thirty hours after 
death. 

In order to ascertain experimentally whether 
blood could occasion a stain, Laennec enclosed a 
quantity in a sound and recent aorta, and placed 
the preparation in the stomach of the subject, in 
order to preserve it from drying, and to put it 
under the same circumstances of decomposition as 
the rest of the body. In twenty-four hours it pre- 
sented a perfect specimen of the scarlet dye, which 
was not weakened by r reiterated washing. Ac- 
cording to his experiments, blood too firmly co- 
agulated causes imbibition feebly and slowly. 
Blood half coagulated, and particularly the blood 
still slightly florid, which may be pressed out of 
the lungs, produces the scarlet redness. Very 
liquid blood, and particularly that with a serous 
intermixture, produces a violet colour of greater 
or less depth. If the artery be only partly filled, 
the dye occupies those parts alone which are in 
contact with the blood, and forms a ribbon. If 
the walls of the artery are firm and elastic, the 
dye requires a long time (seventy or eighty hours) 
for its formation, and is never very deep ; but if, 
on the contrary, the walls are soft, supple, and 
charged with humidity, the dye promptly pene- 
trates through the whole thickness. Warm wea- 
ther and the rapid progress of putrefaction are 
favourable to the imbibition. 

Boerhaave and Morgagni attributed the red 
colour to the stagnation of blood which takes 
place during the agony in diseases accompanied 
with great oppression ; and Hodgson maintains 
that arterial redness, such as that above described, 
does not arise from acute inflammation, as it is 
not accompanied by any other anatomical charac- 
ters of inflammation. When occurring in the 
vicinity of coagula, it is, in his opinion, an effect 
of imbibition after death. 

It is impossible not to conclude from all the 
evidence now adduced, that redness of the inter- 
nal membranes of the heart and arteries cannot 
alone prove inflammation, and that it is a pheno- 
menon taking place during the agony, or after 
death, whenever it is found in conjunction with 
the following circumstances : namely, a prolonged 
and suffocative agony ; manifest alteration of the 
blood ; and a somewhat advanced decomposition 
of the body. 

Such is the redness of the internal membrane 
of the heart and arteries which is not inflamma- 
tory : we now proceed to that which is. The co- 
lour of the latter may be the same , for the mem 



ARTERITIS, 



165 



brane, though inflamed, is still liable to imbibition. 
In the absence of imbibition, the redness is fainter, 
less shining, more equably diffused, and less cha- 
racterised by streaks, patches, isolated unstained 
spots, and abrupt edges. 

Effusion of lymph on the internal mem- 
bltane, with thickening of its sub- 

ST LNCE. 

Whether the redness be due to vascularity 
alone, or to this conjoined with imbibition, its in- 
flammatory nature is known by the presence of 
certain other anatomical characters of inflamma- 
tion. These are, thickening, swelling, and puffi- 
ness of the inner membrane ; and effusion of 
lymph on either its free or adherent surface ; and 
a preternatural vascularity, with softening and 
thickening, of the middle arterial coat. Each of 
the coats may be separated from the other with 
much greater facility than natural by scraping 
with the nail or scalpel. The internal and middle 
coats, in short, present all the phenomena of the 
adhesive inflammation, as it occurs in other mem- 
branes. It is by this inflammation that, if an 
artery be wounded or divided ; if it be compressed 
by a ligature or tumour ; or if it be simply irritated 
by ulceration of the surrounding parts or a pul- 
monary vomica, and effusion of lymph takes place 
into the cavity of the vessel, and into the cellular 
tissue, botli investing it externally, and connecting 
its several coats, by which its caliber is obliterated 
and hemorrhage prevented. 

Although obliteration never takes place in the 
aorta from inflammation alone, this vessel some- 
times exhibits the vestiges of acute inflammation 
more palpably than smaller arteries. Thus, in a 
case seen by Dr. Farre, the internal coat of the 
aorta was of a deep red colour, and a considerable 
effusion of lymph had taken place into its cavity. 
The lymph was very intimately connected with 
the internal coat. (Hodgson on the Arteries, p. 
5, plate 1, fig. 5.) Similar instances have been 
seen by Hodgson, (Ibid. p. 6,) Bertin, (Case ii. 
p. 7,) and apparently by Portal, (Cours d'anato- 
rnie medicale, torn iii. p. 12?,) and Morgagni and 
Boerhaave, (Morgagni, Epist. xxvi. Art. 36 ;) and 
lymph has been found effused within the auricles 
and on the valves by Baillie, (Morbid Anat. Edit. 
5, p. 85,) Laennec, (De l'Auscult. torn. iii. p. 
127,) Burns, (On Diseases of the Heart, ch. ix.) 
We have met with it both in the heart and aorta. 
Effusions of lymph within the heart and great 
arteries, however, are very seldom witnessed ; and 
hence it is, that Laennec thinks inflammation of 
the internal membrane of those parts extremely 
rare. (De l'Auscult. torn. ii. p. 598.) But the 
presence or absence of lymph is not sufficient to 
determine whether inflammation exist or not ; for, 
in many instances, the lymph, when first effused, 
is washed away by the force of a circulation so 
powerful as that in the heart and aorta. Laennec 
considers a layer found on the internal membrane 
of the heart or great vessels, to be the only incon- 
testable sign of inflammation of that membrane, 
and, with ulceration, the only certain one, (Ibid, 
p. 607 :) for he doubts whether iedness of the 
membrane, even when conjoined with thickening, 
swelling, puffiness, and an unusual development 
of small vessels in the middle tunic, would satis- 
factorily prove inflammation in a subject conside- 



rably infiltrated, and whose tissues are very hu- 
mid. (Ibid.) This is a point which can only be 
determined by the judgment of the physician in 
individual cases. We recently met with a case 
precisely such as Laennec describes, and, at the 
first glance, it struck us and two eminent medical 
friends as being inflammatory ; but a brief inspec- 
tion proved the reverse. It is necessary, however, 
to be alive to this source of fallacy. Kreysig, 
Hodgson, and Bertin and Bouillaud are of opin- 
ion that lymph effused by inflammation is the 
source of fungous or warty vegetations of the 
valves. Laennec rejects this opinion, and attri- 
butes the vegetation to sanguineous concretions 
which adhere to the internal membrane, and be- 
come organized. He does not deny, however, 
that an inflammatory false membrane may be- 
come the nucleus of these concretions. This sub- 
ject will be more fully considered under the head 
of vegetations. 

Effusions of lymph are, in some instances, the 
result of chronic inflammations ; for they are found 
in the vicinity of ossifications of arteries and 
other morbid alterations of a chronic nature. We 
have seen an ossified common iliac obliterated by 
a plug of lymph. Hodgson has witnessed nearly 
the same ; and Dr. Goodison found the aorta itself 
obliterated by lymph, at a part where its whole 
circumference was converted into a bony cylinder. 
This lymph must have been, secreted gradually ; 
as the force of the aortic circulation would have 
washed away any soft and copious recent effusion. 
It is probable that the obliteration of arteries in 
the neighbourhood of vomica? and other ulcera- 
tions, and of tumours, is also occasioned by chro- 
nic inflammation. 

Ulceration of the internal membrane. — Ulcera- 
tion of the internal membrane sometimes takes 
place from acute inflammation, without any lesion 
of the subjacent tissues. This, however, is rare ; 
for, in general, the ulceration is a consequence of 
some previous chronic degeneration of the coats 
of the vessel, and is, in the first instance, rather a 
solution of continuity than an ulceration. Such 
is the case when it is occasioned by the detacn- 
ment of calcareous incrustations, or by the depo- 
sition of atheromatous or other matter underneath 
the internal membrane. Ulcers from these causes 
are not uncommon, and though they do not, 
strictly, come under the head of acute arteritis, 
they may be conveniently considered in this situa- 
tion. They vary in size from a mustard-seed to a 
pea or bean, have more or less thick and ragged 
edges, and are sometimes so deep as to reach, and 
even to perforate, the external or cellular tunic. 
Laennec describes the formation ot these ulcers 
from calcareous incrustations in the following 
manner : "When a calcareous incrustation," says 
he, " is detached from the aorta, the species of 
sinus left by it is filled up by fibrine, which he- 
comes, by decomposition, of the consistence of 
friable paste, and is often intermixed with phos- 
phate of lime." This paste, when soft and pulpy, 
has been denominated melicere, or atheroma. 
Not unfrequently, the borders of the lesion aro 
reddened for a little distance; and this he attributes 
to imbibition of blood, (rendered more easy in an 
altered structure,) rather than to chronic inflam 
mation, which he thimks is not proved either I* 



166 



ARTERITIS, 



(he presence of pus, or of any symptom-:, local or 
general, that can be referred to it. These lesions, 
therefore, he regards as being, in the lirst instance, 
merely solutions of continuity from an entirely 
mechanical cause; and not ulcers, occasioned by 
inflammation. He does not deny, however, that 
the oldest and most extensive of them sometimes 
become ulcers ; for the internal membrane at the 
borders of the lesions is slightly tumid and red, 
and the surface of the fibrous tunic at their base 
is manifestly altered. But he contends that the 
inflammatory action which gives them the charac- 
ter of ulcers, is the effect, not the cause, of the 
solution of continuity. Solutions of continuity 
occasioned by the detachment of calcareous in- 
crustations, are among the most frequent causes 
of consecutive false aneurisms. 

Small pustules filled with pus sometimes, though 
rarely, present themselves under the internal mem- 
brane of the aorta, and burst into its cavity. It is 
probable that they form the genuine or primitive 
ulcers of that vessel. — those which are the most 
frequent cause of its perforation. They sometimes 
throw out curdy, and even calcareous matter. 
Laennec thinks that these pustules are occasioned 
by inflammation, not of the internal, but of the 
middle arterial tunic, or of the fine cellular tissue 
which unites the middle to the internal tunic; and 
he is of this opinion, because, in inflammation of 
all membranes, as the peritoneum, the pleura, the 
mucous membrane lining the bronchia, &c. pus 
forms on their free, and not on their adherent sur- 
face. Therefore, as this secretion is found on the 
adherent surface of the inner arterial membrane, 
he infers that the inflammation occasioning the 
pustule is seated, not in that membrane, but in 
the subjacent tissues. Pus is scarcely ever found 
on ulcers of the heart and arteries, because it is 
washed away as soon as secreted. For the same 
reason, it is never found on the internal surface of 
arteries that are inflamed without being ulcerated, 
though analogy leads us to believe that, under 
these circumstances, it is secreted. 

Ulcerations are extremely rare in the cavities of 
the heart. We recently met with an instance, 
originating in a curdy deposition under the lining 
membrane. We have never seen or heard of a 
case in which inflammation, when confined to the 
interior of an artery, terminated in gangrene. 
Arteries, however, are frequently involved in the 
sloughing of surrounding parts ; in which case 
tne blood generally coagulates in the vessels to a 
considerable extent above the line of sphacelation, 
and thus prevents hemorrhages. (Hodgson, p. 17.) 

It remains to be noticed that arteritis is some- 
times of an erysipelatous nature. We allude to that 
which follows an injury of an artery, as by a ligature. 
a gun-shot wound, &c. especially if there be deep- 
seated disease in the muscles of the part affected. 
The inflammation, in these cases, sometimes runs 
along the internal coat of the artery till it reaches 
the heart. It is a most formidable disease, rapidly 
producing great irritative fever, an extremely quick 
pulse, complete collapse, low delirium, and gene- 
rally deat K 

Chronic arteritis ash the morbid alter- 
ations CONNECTED WITH IT. 

Arteries are more subject to chronic than to 
•cute inflammation. The internal membrane, 



| when so affected, is thickened, softened, and d a 
deep dirty red colour. These appearances are not 
uniformly diffused, but are more marked in the 
vicinity of calcareous and other degenerations. 
Hence some have supposed that these degenera- 
tions were the cause of the inflammation. There 
can be little doubt that they tend in many in- 
stances to keep it up ; but it is highly probable 
that the degenerations themselves were originally 
caused bv increased vascular action of a chronic 
nature. Whether the increased vascular action 
be in every case, particularly those of calcareous 
depositions, strictly inflammatory, we shall inquire 
after bringing the various degenerations under 
review. Meanwhile it may be remarked that the 
appearances in arteries presented by chronic in- 
flammation accompanied with morbid depositions, 
have been well known to authors from a very early 
period. The ancient physicians ascribed them to 
acrimonious, syphilitic, and scorbutic humours 
pervading the system. Some modern writers also, 
particularly Corvisart, Scarpa, Richerand, and 
Hodgson, impute them to similar causes, espe- 
cially to the syphilitic virus, or to the mercury 
used for its eradication. 

MoilP.in ALTERATIONS IN THE COATS OF ARTE- 
RIES, AND ESPECIALLY OF THE AORTA. 

The morbid alterations in the interior of the 
aorta which appear to be of chronic formation, 
are, steatomatous, fibrous, cartilaginous, and calca- 
reous depositions, with a thickened, fragile, and 
inelastic condition of the arterial coats. The most 
simple of these alterations is, a loss of elasticity, 
generally accompanied with increased density and 
opacity of the coats of the artery. This state is 
sufficient of itself to give rise to dilatation, by a 
process which will be described under the head of 
dilatation of the aorta. 

Before describing the depositions, it may be 
premised that they originate, not in the internal 
coat, but either in the middle coat, or in the fine 
cellular tissue interposed between it and the inter- 
nal coat ; that this coat can sometimes be peeled 
off from them in a perfect state, even when they 
are far advanced ; and that the productions them- 
selves are more analogous to those of a fibrous 
than of a serous membrane. 

The extent, the form, and the thickness of the 
productions are infinitely various : sometimes the 
several species exist separately, but more com- 
monly they are found more or less intermingled 
in the same artery. The first and most common 
appearance is that of small, opaque, straw-coloured 
spots, immediately underneath the lining mem- 
brane, with slight inequality and corrugation of 
the membrane around them. At a more advanced 
period the depositions form considerable, slightly 
elevated patches, which, becoming confluent, 
sometimes overspread the whole surface. Some 
of these patches have much the appearance and 
consistence of bees'-wax, or cheese, though in 
general their cohesions and flexibility are greater. 
These are usually denominated steatomatous. 
Others, presenting nearly the same colour, have a 
fibrous or ligamentous appearance ; while others, 
again, are more translucent, white, and elastic- 
like cartilage or fibro-cartilage. All the deposi- 
tions described are accompanied with thickening 
and loss of elasticity of the internal coat, which 



ARTERITIS, 



107 



recomes knotty, wrinkled, and sometimes cracked, 
scaly, and fimbriated. This, however, is less deci- 
dedly the case until earthy depositions have taken 
place. These generally commence in the midst 
of a cartilaginous or fibrocartilaginous patch, 
though they are sometimes found in detached 
scales, and sometimes in a soft or pasty form, in 
the midst of cheesy, curdy, or melicerous matter. 
When they form incrustations, the shape of these 
is irregularly flattened ; the prominences being 
towards the exterior rather than the interior of the 
artery. Their external surface sometimes presents 
the imprint of the circular fibres of the middle 
tunic. Their internal surface is sometimes 
smooth, and evidently covered by the membrane ; 
in other cases it is rough, and the membrane is 
more or less destroyed. Calcareous depositions 
occur most frequently in the ascending portion 
and arch of the aorta, but occasionally they per- 
vade the whole of the vessel, and even almost the 
whole of the arterial system. We saw a case in 
the Hotel Dieu, in which the great arteries from 
the heart to the ankle were converted into rigid 
tubes by ossification, which in parts occupied all 
the coats and the whole circumference of the ves- 
sels. In another case, at St. George's Hospital, 
the common iliacs were rigid ; and one of them, 
which was converted into a long cylinder, was 
obliterated by a plug of dense lymph. The arte- 
rial system was elsewhere more or less ossified. 
Both the patients died with gangrenous sores of 
the legs. 

In the arteries at the base of the brain, calcare- 
ous and other degenerations are remarkably fre- 
quent, and are a principal cause of apoplectic effu- 
sions. It is rare, indeed, to meet with an instance 
of such effusion, exclusive of those dependent on 
external violence, in which some disease of these 
arteries may not be detected ; and it may be 
remarked in passing, that, in most instances, the 
disease of the artery is connected with hypertro- 
phy of the left ventricle ; whence it appears to be 
referable to over-distension, to which the cerebral 
arteries are more obnoxious than others, in conse- 
quence of their being without the cellular coat, 
and being ill-supported by the pulpy yielding suh- 
stance of the brain. We have met with several 
cases of epilepsy which had no other obvious 
cause than disease of the cerebral arteries. The 
arteries below the pelvic divarication of the aorta 
are more frequently ossified than those of the 
upper extremities and trunk. 

Calcareous concretions differ essentially from 
natural bone. For though some are formed by 
the secretion of the earthy phosphate in cartilage, 
even these have not the peculiar fibrous arrange- 
ment of bone. But in by far the greater number 
of cases, the earthy matter is not secreted in any 
cartilaginous matrix whatever, but is simply depo- 
sited in the form of an irregular homogeneous 
crust or crystallization, without any determinate 
arrangement, and without vitality. The propor- 
tion of animal matter in these is very small. Mr. 
Brande found 100 parts to consist of 65.5 of 
phosphate of lime, and 34.5 of animal matter. In 
some specimens we have found the quantity of 
animal matter considerably less. 

When ossification is very considerable, it is 
sometimes attended with induration, inelasticity. 



and fragility, not only of the internal, but of al! 
the arterial coats ; and this state I have seen at- 
tended in some cases with thickening, and in 
others, though less frequently, with extenuation 
and a horny translucency of the walls of the ves- 
sel. The aorta, so affected, generally undergoes 
dilatation, but very rarely contraction. When the 
depositions are partial and limited, the internal 
membrane in the intervals is often perfectly sound. 
This is especially the case in the ossifications of 
old people. It is remarkable that, though morbid 
depositions are so frequent in the aorta, they are 
extremely rare in the pulmonary artery. Out of 
upwards of a thousand cases, in which we have 
examined this vessel, we have never met with cal- 
careous depositions in its coats, and only three or 
four times with cartilaginous and steatomatous 
disease and dilatation. 

Causes of morbid depositions in the coats 
of Arteries. — Some authors have considered 
morbid depositions in the coats of arteries to be, in 
every case, the various metamorphoses of lymph, 
effused by inflammation of the acute kind and of 
such intensity as always to proclaim itself by ob- 
vious symptoms, and require antiphlogistic treat- 
ment. Others, again, have supposed that many, 
if not all, of the depositions in question, take place 
quite independently of inflammation of any kind. 
As principles of treatment of a decided nature 
have been founded on each of these conflicting 
doctrines, it is a matter, not of mere speculation, 
but of practical importance, to look into the sub- 
ject, and endeavour to ascertain the truth. 

Although it would be difficult to deny that acute 
inflammation may, in some instances, lay the 
foundation of morbid depositions in the coats of 
arteries ; yet it is certain that they may and do 
occur independent of it ; as they have been found 
in individuals who had never manifested any 
symptoms whatever of inflammation, and who 
had even constantly enjoyed the most perfect 
health. Analogical evidence derived from other 
membranes leads to the belief that chronic inflam- 
mation is, in most instances at least, the main 
agent concerned in the production of these depo- 
sitions. Thus, for example, the dura mater and 
the pleura are sometimes not only thickened and 
indurated, but converted into fibrous, cartilaginous, 
or bony tissue. We have seen the dura mater 
converted into a calcareous plate nearly as large 
as the hand, and overspreading one hemisphere of 
the brain. The preparation was shown to us by 
Professor Monro, and is in his museum. Mr. 
Hammick showed us two preparations, in his mu- 
seum, of calcareous plates, of about two inches in 
diameter, on the pleura. Changes of this kind 
are, by general consent, attributed to chronic in- 
flammation ; as they are not only found in con- 
junction with organized adventitious membranes 
and other anatomical proofs of that form of in- 
flammation, but are often attended with its syinp 
toms. It is to be presumed, therefore, that cor- 
responding changes taking place within an artery 
are referable to the same cause. That the morbid 
depositions in the artery should not be exactly 
identical with those found in other membranes is 
to be anticipated on principles of general anaio 
my ; for the effused matter, which is the basis o r 
every accidental production, differs in aspect an' 1 



168 



ART Ei / *S 



nature according to the tissue in which it occurs. 
Thus, as well remarked by Bertin, the cellular 
tissue and parenchymatous organs secrete pus, 
properly so called ; thus serous membranes secrete 
a coagulable matter prone to transform itself into 
cellular or serous layers j thus the periosteum fur- 
nishes another matter, which concretes, hardens, 
and ossifies ; thus the arterial tissue, composed 
essentially of a fibrous membrane, exhales a liquid 
which hardens, condenses, and becomes convert- 
ed into cartilaginous patches, or calcareous scales. 

But admitting the agency of chronic inflam- 
mation as a cause of morbid alterations in arte- 
ries, there is reason to believe, as before stated, 
that some of them, particularly the calcareous, 
may take place independently of it; for they are 
found in most old people ; they sometimes occur 
in various detached points very remote from each 
other ; they often consist of a simple calcareous 
scale, or an opaque yellow spot, without any mor- 
bid state of the surrounding membrane ; and such 
alterations almost always take place without afford- 
ing the slightest sign, either general or local, of 
their formation. Now, it is scarcely possible to 
conceive an inflammation which manifests no 
symptoms, which is restricted to isolated points 
often remote from each other, which leaves none 
of the ordinary vestiges of inflammation in the 
surrounding membranes, and which is the most 
frequent at that period of life when phlogistic ac- 
tion is the least prevalent. We are brought, then, 
to inquire, what is the cause of morbid depositions 
when they do not appear to be referable to inflam- 
mation. 

Here it is necessary to proceed with caution, as 
the ground is purely speculative. Laennec, in- 
deed, thinks it the most simple and philosophical 
to acknowledge that we know not the derange- 
ment of the economy which produces an ossifica- 
tion or a cancer, but that very certainly it is not 
the same as that which produces pus — as inflam- 
mation, (De l'Auscult. vol. ii. p. 684.) If we are 
not satisfied to remain in this circumspect uncer- 
tainty, we can scarcely venture farther, in the ac- 
tual state of our knowledge, than to suppose that 
morbid productions are sometimes results of a de- 
praved action of the vessels not identical with or 
not amounting to inflammation — a doctrine, in- 
deed, which rests on the basis of sound observa- 
tion, and which has been extensively received, 
since the accurate researches of the present cen- 
tury have bred a "philosophic doubt" on the 
tenet of the ancients, that all accidental produc- 
tions are the effects of inflammation. Admitting 
a depraved action of the vessels, it is rational to 
suppose that, like inflammation, it would derive 
its particular character from the tissue which it 
affects : hence that the fibrous and fibro-serous 
tissues of the arteries would degenerate into car- 
tilage, bone, &c — the changes to which they are 
most prone under the influence of inflammation. 
But what is it that calls this depraved action into 
activity ? It appears to us fh*» over-distension 
of the arteries by the force of the circulation is 
what, principally at least, produces the effect. To 
(his opinion we are led by the following conside- 
rations : that arterial ossifications are the most 
common when the left ventricle is hypertrophous ; 



that (according to an observation of Boerhaave, 
related by Morgagni) they are found in stags long 
and often exercised in running, r.nd not in those 
which lead a tranquil life in the j trks of the great; 
that diseases of arteries and aneurism are more 
common, in the proportion of at least seven or 
eight to one, in men than in women, the life of 
the former being much more laborious and the cir- 
culation more liable to excitement from potation 
of vinous or spirituous liquors, &c; that ossifi- 
cations, &c, occur in those arteries more especial- 
ly which are most exposed to over-distension, 
namely, the arch of the aorta, which immediately 
sustains the whole brunt of the left ventricular 
contraction, and the arteries of the brain, which, 
not having the support of a cellular sheath, and 
being bedded in a soft puffy substance, are weaker 
than any others ; that they are more especially 
incident to the aged, in whom the arterial and all 
other tissues sustain a diminution of elasticity and 
cohesiveness in consequence of the diminished 
vascularity which characterises old age. Perhaps 
the same reason, viz., over-distension, may be as- 
signed for the remarkable frequency of the arterial 
depositions in those who have suffered much from 
syphilis or mercury ; for as these maladies induce 
a cachectic state which lessens the elasticity of all 
the tissues, the arterial tissue would, under these 
circumstances, suffer proportionably more from 
the distensive pressure of the circulatio 1. To the 
above catalogue we may perhaps add gout — an 
affection which is remarkably often attended with 
arterial ossifications and their frequent concomi- 
tant, angina pectoris. For the gouty habii is in 
general accompanied with a morbid degree of ple- 
thora, and consequently with over-tension of the 
arterial system, leading to ossification. 

It may be remarked, finally, that even they who 
attribute all the morbid alterations in arteries to 
inflammation, admit the necessity of specific in- 
flammations to account for those alterations which 
are not normal products of ordinary inflammation. 
Thus Kreysig thinks that calcareous incrustations 
are only produced by gouty inflammation ; and 
Bouillaud, who employs the word inflammation 
in perhaps too extended a sense, believes that there 
must be a. peculiar predisposition for each effect 
of the one same cause, — that every variety of de- 
position must be the result of a different specific 
inflammatory action. 

Symptoms and diagnosis of acute Arte- 
ritis. — The diagnosis of arteritis is one of the 
most difficult in the range of medicine; as the 
malady presents no signs that are peculiar to itself, 
and distinguish it from other diseases. 

We shall first describe the signs by which some 
authors have imagined that they could detect acute 
aortitis, and then subjoin the sources of fallacy to 
which, according to our experience, those signs 
are liable. The practitioner, being thus warned 
against the various causes of deception, will be 
better able to give their full value to the signs 
themselves ; and he may in this way, we think, 
make out the diagnosis with some success. 

The principal sign of acute aortitis, according 
to authors, is a pulsation of the aorta much more 
violent than in the healthy state. A pain and 
sensation of heat in the region of the aorta, anxi- 



ARTERITIS, 



169 



ety, ana faintishneas, arc symptoms of a less con- 
stant nature, but which, nevertheless, it is import- 
ant to mark. To these are to be added accelera- 
tion of pulse, heat, and dryness of the skin, thirst, 
anorexia, and all the other concomitants of phlo- 
gistic action. The position of the thoracic aorta 
is such that the strength of its pulse can only be 
explored in the hollow at the summit of the ster- 
num and above the clavicles. The beating of the 
ventral aorta may be more easily examined, name- 
ly, by applying the hand, or, what is better, the 
stethoscope, on the abdomen. 

Violent pulsation of the aorta from inflamma- 
tion is often accompanied with a similar pulsation 
in any or all of the great arteries ; the reason of 
which is, that the inflammation not unfrequently 
extends to the other arteries, and even to the 
whole of the arterial system. 

With respect to inflammation of the internal 
membrane of the heart, it is excessively rare in 
an isolated form, being almost invariably attended 
either with carditis or pericarditis. Analogy indi- 
cates that it ought to be characterized by augmen- 
tation of the force and frequency of the action of 
the heart and arteries, and leads us to expect that 
when the inflammation reaches and disorganizes 
the muscular substance, it would render it inca- 
pable of contracting with its natural strength and 
regularity. Observation confirms what analogy 
leads us to foresee. In fevers, properly so called, 
which appear to be constantly accompanied with 
an irritation of the heart, the frequency and force 
of the pulse are the two principal phenomena that 
strike our senses ; but should the fever assume a 
typhoid type, and give rise to an irritation of the 
heart, so profound that the muscular substance is 
itself attacked, the pulse loses its force and regu- 
larity while it augments in frequency, an unex- 
pected death often terminates this always formi- 
dable complication. Should the patient recover, 
the slowness of his convalescence and the fre- 
quency of pulse which characterize it, are probably 
dependent cither on an irritable state of the inter- 
nal membrane left by the inflammation, or on soften- 
ing of the muscular substance, — a subject to which 
we shall revert when treating of softening. 

Such are the symptoms of acute arteritis as- 
signed by authors. The fallacies to which they 
are liable are so numerous that many able practi- 
tioners formally avow their inability to make the 
diagnosis. The fallacies arise, 1st, from the in- 
flammatory complications with which arteritis, and 
more particularly aortitis, is accompanied : 2dly, 
from affections which, though unattended with 
arteritis, occasion arterial pulsation. 

1. The inflammatory complications of aorti- 
tis Acute aortitis is very rarely known to exist 

(so far as we can judge from its anatomical ves- 
tiges — the only positive criteria) independent either 
of continued fever, or of inflammation of some 
of the principal viscera, particularly the lungs, 
pleura, and pericardium. In these complicated 
cases the symptoms of aortitis are lost in those of 
the concomitant malady, which is of itself capable 
of producing, to a greater or less extent, the same 
violent arterial pulsation and the same anxiety 
and faintishness as are considered characteristic 
of aortitis. 

Vox.. I. — 22 p 



2. Affections which, though unattended with 
arteritis, occasion arterial pulsation. 

(a.) When the interior of the ascending por- 
tion, or arch of the aorta is ossified or cartilagi- 
nous, there is generally a preternatural pulsation 
above the clavicles, and this always takes place 
when the artery is dilated ; for, as the blood per- 
meates the diseased or dilated portions with greater 
difficulty than others, in consequence of its being 
reverberated in counter-currents and eddies from 
prominences in the vessel, those portions sustain, 
at each contraction of the heart, an increase of the 
expansive force of the blood, the lateral pressure 
of which is always augmented in proportion as the 
direct current is impeded. 

(b.) Persons of an irritable temperament, espe- 
cially delicate hysterical females and hypochon- 
driacal males, are subject to morbid arterial pulsa- 
tion, sometimes confined to the aorta alone, and 
sometimes universal throughout the system. When 
it is seated in the descending aorta, the patient 
complains of " a fluttering " in the epigastrium. 

(c.) Morbid arterial pulsation is a phenomenon 
of reaction after loss of blood — a fact to which the 
attention of the profession has been drawn with 
great ability by Dr. Marshall Hall, and which we 
have verified, not only by observations on the 
human subject, but by extensive experiments on 
animals, performed in concert with that gentleman. 
The pulsation not unfrequently supervenes, and 
subsists for a considerable time, after the free de- 
pletions necessary for the cure of acute inflam- 
matory affections, as pleuritis, pericarditis, peri- 
pneumony, phrenitis, peritonitis, &c. In these 
cases it would be a dangerous error to suppose 
that the pulsation depended upon aortitis. 

(c?.) We have found arterial pulsations to ac- 
company adhesion of the pericardium, especially 
for the first year or so after the attack of pericar- 
ditis which occasioned it. The phenomenon is 
attributable to the jerking and, as it were, spas- 
modic manner in which the heart contracts under 
such circumstances. It may be remarked that 
there was adhesion of the pericardium in two of 
the three cases from which more especially Berlin 
and Bouillaud derive their opinion that aortic pul- 
sation is always a sign of aortitis. (Bertin, Obs. 
xxvii. xxviii. and xxix.) 

(e.) Tumours, serous effusions, &c. in contact 
with the aorta, give it the character of preternatu- 
ral pulsation, as they transmit its impulse more 
strongly than the parts which properly environ it. 
The mode of distinguishing these pulsations is 
treated of under the diagnosis of aneurisms of the 
aorta. 

From this long catalogue of fallacies it will be 
apparent that the diagnosis of arteritis is beset 
with much difficulty. Still, it is not wholly hope- 
less ; for, by a negative process, — by ascertaining 
that the pulsation is not attributable to any of the 
causes mentioned, — I believe it is possible to form 
an opinion which will not be very wide of the 
truth. 

Of chronic arteritis, it is sufficient to say, that, 
though it in all probability deteriorates the general 
health, it presents no distinctly appreciable signs 
but those of the structural alterations, — the depo- 
sitions, dilatations, and valvular obstructions, — to 
which it gives rise. 



170 



A ITI8AN8, (DISEASES OF) 



Prognosis. — Arteritis is not a dangerous dis- 
ease by its immediate effects; hut it may lay the 
foundation of disease of the arterial coats and 
valves of the heart, which may ultimately prove 
formidable by inducing aneurism of the vessels 
and disease of the heart. When arteritis is com- 
plicated with fevers, or visceral inflammations, the 
prognosis must be founded on the symptoms of 
the latter maladies. 

Treatment of arteritis. — Arteritis is to be 
treated on the same general principles as any other 
inflammation ; namely, by bleeding, purgatives, 
retics, low diet, cooling diluent drinks, and 
tranquillity. The latter is absolutely ne- 
. as any efforts which accelerate the circu- 
lation increase the tension, and therefore the irri- 
tation, of the arterial system. On the same prin- 
ciple, remedies which calm the circulation, as digi- 
talis, tartrate of antimony, superacetate of lead, 
are useful auxiliaries when discreetly employed ; 
but they should not supersede the more important 
remedies above mentioned, nor should they be 
given at a late period of the disease, when the 
symptoms, which of themselves become compli- 
cated, should be kept as unembarrassed and clear 
as possible. When mercury is not contra-indi- 
cated by a strumous or shattered constitution, its 
exhibition to the extent of slight but prompt sali- 
vation, after the first violence of inflammatory 
action has been repressed, is attended with excel- 
lent effects. 

When arteritis is complicated with visceral in- 
flammation or fever, the treatment must be directed 
to the primary malady. 

J. Hope. 

[ARTHRITIS. See Gout.] 

ARTISANS, Diseases of. — The diseases of 
artisans must, in every civilized country, be an 
object of great importance, but in none can it be 
so important as in Great Britain, so large a pro- 
portion of whose inhabitants are engaged in manu- 
factures. In the present article we propose to 
give a brief account of these diseases, and to ac- 
company it, as far as we can, by that of the 
attempts which have been made to deprive the 
various trades of their injurious tendencies. 

The arrangement which we shall follow will, 
with some modifications, be that which was first 
indicated by Ramazzini, modified by Fourcroy, 
and again modified by M. Patissier. The ground- 
work of the arrangement is founded upon the 
causes of these disorders; and we, first of all, 
have two classes. The first includes the diseases 
caused by moleculse, which, mixed with the air in 
the form of vapour or fine powders, are respired 
by the workmen, penetrate their organs, and dis- 
turb their functions. The second class compre- 
hends the diseases caused by excess or defect in 
the exercise of certain parts of the body. Under 
the first class are comprehended, 1. diseases pro- 
duced by mineral moleculae ; 2. those arising from 
animal molecular ; 3. those which result from 
vegetable molecula; ; and 4. diseases which are 
oroduced by the mechanical action of molecula; 
or fine powders, arising from mineral or vegetable 
substances. The second class embraces, 1. dis- 
eases arising from the effects of moisture and of 
temperature ; 2. diseases from undue or excessive 



muscular exertion of particular parts or organs ; 
3. diseases arising from sedentary habits. 

Before entering thus upon the effects of peculiar 
substances and the effect of particular positions, a 
preliminary inquiry ought to be made into the 
consequences of labour abstractedly taken. There 
is unquestionably considerable difficulty attending 
it ; but vet it seems impossible to reject over-con- 
finement alone, or over-exertion alone, as produc- 
tive of severe maladies. We are accustomed fre- 
quently to witness the consequences of ov, r- 
working that most useful animal, the horse ; and, 
in this respect at least, there is nothing physically 
different between man and the otier mammalia. 
In the horse, the kind of labour has evidently 
nothing to do with it, since the same exercise, 
moderately taken, contributes to the preservation 
of his health and the improvement of his strength; 
it is the quantity alone to which the injury is to 
be referred. The same remark holds equally good 
of man, but very many circumstances attending 
his occupations will require to be taken into 
account. In the first place, the quantity of labour 
which different individuals can undergo without 
detriment, will vary much with the original con- 
stitution of their bodies and their habits. A man 
of great natural physical strength, other things 
being equal, wdl perform more labour than a man 
of less powerful make ; o